Appeals Writer | Registered Nurses  

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.

Functional Area Outcomes and Expectations

· Able to produce excellent written, verbal, and professional letters.

· Produce quality decisions in handling clinical and non-clinical disputed claims whether it needs to be appealed or routed to different department.

· Participate in process-related meetings e.g. calibration sessions

Maintain ethical and good teamwork atmosphere in the team by participation through a Ways of Working document.

Knowledge, Skills and Abilities

· Demonstrates ability to manage stress through critical thinking, problem solving, and fair and independent decisions supporting the clinical appellate process.

· Demonstrates proficiency in use of medical necessity criteria sets, MCG and InterQual®, as evidenced by Inter-rater reliability studies and other QA audits.

· Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs) Authorization log, InterQual®, VI, HPF, Meditech, as well as competency in Microsoft Office to increase level of ease in multitasking

· Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.

· Critical thinker, able to make decisions regarding medical necessity independently

· Ability to interact intelligently and professionally with other clinical and non-clinical partners

· Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms

· Ability to multitask

· Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.

· Ability to conduct research regarding off-label use of medications and payor-policy bulletin