Clinical Appeals Auditor
Remote Clinical Appeals Auditor
The purpose of this role is to support a national team by providing client services related to clinical review, appeals and denials management. This position will be responsible for working effectively with payers and providers, along with different members of the internal team of Clinicians, Nurses, Occupational Therapists, Physical Therapists, and Physicians.
Manages denials and appeals in a manner that diligently investigates every unpaid claim
Assesses the need for formal appeals of all clinical denials
Appeals the rejections appropriately as per the appeals process for the provider contract
Reviews and audits clinical documentation to ensure its sufficiency
Utilizes various resources in order to understand the appeals and denials criteria; searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable
Adheres to all appeal timelines as prescribed by payer agreements
Employs the use of different systems to evaluate clinical and financial data
Uncovers trends related to different cases and various insurance carriers; maintains related data and monitors payer response to appeal activity
Provides information to leadership on patterns or trends associated with denials and appeals
Evaluates and adheres to all clinical and billing policies, guidelines and regulations of both commercial and governmental payers
Takes steps necessary to understand the quality assurance requirements to ensure procedural compliance
- Participates in revenue cycle process improvement projects
- Completes other duties as assigned
???????Preferred Experience and Skills
Minimum Degree: Bachelor’s degree or higher in nursing; current RN licensure
Minimum Years of Experience: 5+ years of experience in a clinical and business setting
Software/Systems Experience: Interqual and/or Milliman
Recruiting Solutions provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Recruiting Solutions complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.
Recruiting Solutions expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status.