Clinical Denials Clinician
Job Description:
The Clinical Denials Clinician of AR Management is responsible for recovering revenue through a.) intelligent and ethical investigation of disputed/denied clinical claims, b.) verifying eligibility for clinical review, and c.) preparation and documentation of appeals based on industry-accepted criteria. He / She is also relied on when it comes to synergizing with the Denials team on processes and best practices.
Responsibilities and Duties:
- Serves as a resource to non-clinical personnel
- Provides Clinical Resource Center (CRC) leadership with sound solutions related to process improvement
- Assists in development of policies and procedures as business needs dictate
- Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.
- Performs retrospective (post-discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
- Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate module of evidenced-based medicine guidelines (InterQual criteria (Acute, Procedures, etc), MCG Guidelines, or Payer Specific Guidelines). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
Required Certifications/Licensure:
- Minimum of 1-year Medical Necessity Appeals Writing experience in a provider or payor setting
- Medical-surgical/critical care experience; managed care payor experience either in Utilization Review, Case Management or Appeal; Minimum of 1-year recent acute care experience in a facility environment
- Preferably possess a valid nursing license, advanced medical degree such as Occupational Therapy (O.T.), Physical Therapy (P,T.) or Medical Doctor (M.D.) with previous appeal writing experience.
- Current, valid RN licensure; Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM)
Working Conditions:
- Amenable to work in BGC, Taguig (hybrid)
- Willing to work in a dayshift schedule
Company Benefits:
- Competitive Salary
- HMO on day 1 plus 1 dependent; Additional 2 HMO dependents upon regularization
- Group life insurance
- PTO Credits
- Annual Appraisal
- Annual Performance Bonus
