- Clinical Denial Review and Analysis:
- Perform comprehensive reviews of denied claims, focusing on clinical issues such as medical necessity, level of care, non-covered services, and authorization-related denials.
- Conduct thorough analysis of patient medical records, payer medical policies, and relevant medical necessity criteria (e.g., InterQual, Milliman) to build a robust clinical case for appeal.
- Identify gaps in clinical documentation and collaborate with other team members to gather the necessary supporting evidence for a successful appeal.
- Appeal Generation and Submission:
- Independently write professional, persuasive appeal letters that present a compelling clinical argument for payment.
- Leverage generative AI tools to assist in drafting initial appeal letters, increasing efficiency and allowing focus on the most complex cases.
- Ensure all appeals are submitted accurately, within payer-specific timelines, and tracked through to final resolution in the Pulse platform.
- Collaboration and Process Improvement:
- Work closely with the Payer Contract Specialist, Certified Coders, and Revenue Recovery Specialists to ensure a holistic and coordinated approach to each appeal.
- Identify and report emerging denial trends to team leadership to support root cause analysis and the development of denial prevention strategies.
- Assist in creating and maintaining standardized appeal letter templates for various denial types and payers to improve team efficiency.
KNOWLEDGE, SKILLS, AND ABILITIES:
- Strong clinical acumen with the ability to critically analyze medical records and justify the medical necessity of services rendered.
- Exceptional written communication skills, with the ability to craft clear, concise, and persuasive arguments.
- Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.
- Comfortable navigating and troubleshooting various applications, including Microsoft Office Suite, data management systems, and virtual collaboration tools.
- Highly organized, self-motivated, and able to work independently to manage a caseload and meet deadlines.
- Familiarity with medical billing, coding principles (ICD-10, CPT), and payer reimbursement methodologies.
WORK EXPERIENCE, EDUCATION AND CERTIFICATIONS:
Active and unrestricted Registered Nurse (RN) license.
Bachelor of Science in Nursing (BSN) preferred.
Previous experience in denial management or clinical appeals role.
Minimum of 2-3 years of clinical experience in a hospital or healthcare setting. Experience in Case Management, Utilization Review, or Clinical Documentation Improvement (CDI) is highly desirable.
Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.
WORKING CONDITIONS AND PHYSICAL REQUIREMENTS:
- 100% Remote
- Reliable high-speed internet connection is required for all remote/hybrid positions.
- Must have access to stable Wi-Fi with sufficient bandwidth to support video conferencing, cloud-based tools, and other online work-related activities.
- A HIPAA-compliant work environment is required, including a secure workspace free from unauthorized access or interruptions, no use of public Wi-Fi unless connected through a secure company-provided VPN, and compliance with all applicable HIPAA privacy and security regulations.