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Clinical Appeal Denial Writer
Clinical Appeal Denial WriterHudson Regional Hospital • Clifton, NJ, US
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Clinical Appeal Denial Writer

Clinical Appeal Denial Writer

Hudson Regional Hospital • Clifton, NJ, US
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  • [job_card.full_time]
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Position Summary

Manages and reviews clinical denial appeals to payers.

Job Duties

  • Coordinates appeal for clinical denials to managed care/insurance companies and governmental agencies.
  • Writes clinical appeals and audits patient medical and billing records to determine documentation and items billing are appropriate.
  • Follows through to ensure that audit adjustments are made and corrective actions are taken to address identified billing, charging, and documentation issues.
  • Prepares first, second, and third level appeals utilizing relevant clinical information and professional standards and guidelines.
  • Collaborate with each hospital physician advisors and Utilization/Case Managers.
  • Performs other duties as assigned
  • Possesses and consistently develops the ability to understand medical policies for commercial carriers to determine the medical necessity for audits.
  • Remains current with all governmental regulations and policies related to audits including RAC and others. Maintains working knowledge of governmental regulations for billing purposes when performing audits.
  • Proposes language changes because of denial reviews and observations.
  • Obtains a thorough understanding of managed care contracts as part of appeal process.
  • Collaborates with physicians and leadership to enhance denial management and improve clinical documentation improvement efforts.

Qualifications and Skills

  • Clinical knowledge to denial appeals process.
  • Knowledge of regulatory and payer requirements for reimbursement and reasons for denials by auditors.
  • Outstanding organization skills.
  • Excellent verbal and written communication skills.
  • Proficient in Microsoft Office.
  • The ability to quickly gain comfort with other software programs needed to perform the essential functions of the position.

Education, Experience and Certification/Licensure Requirements

  • Thorough understanding of clinical processes and knowledge of billing, coding and Milliman Care Guideline (MCG) criteria.
  • Three years of experience in acute care utilization review is preferred. Minimum of 1 year Clinical Medical Necessity Appeals preparation.
  • Active RN license in the state of NJ. BSN preferred.
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Clinical Appeal Denial Writer • Clifton, NJ, US

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