Appeal and Audit Coordinator
- Using evidence-based criteria, conducts medical necessity review, based upon denial root cause, to prepare the denial argument for all levels of appeals
- Prepare and present case studies with the respective source of denial (Case Management, Physicians, payer, et al)
- Develops, maintains, and manages cases utilizing an internal software appropriate (i.e. denial/appeal summary, outpatient denial summary and audit summary)
- Identifies, monitors and presents monthly denial performance accompanied with case studies and recommendations for process improvements
- Participates in external payer meetings, presenting payer performance related to denials
- Serves as the Subject Matter Expert (SME) for clinical denials documentation and payer clinical guidelines
- Consult with other disciplines and other ancillary departments (i.e. physician, coding, OR, cardiology, pharmacy, purchasing, case management, respiratory therapy, clinical documentation specialists, etc.) as needed to obtain necessary documentation to support clinical appeal and implement prevention
- Responsible for denial reduction through prevention and increase denial recovery through disputes
- Performs other duties as assigned
Required Knowledge and Skills:
- Expert in evidence-based criteria, including InterQual, Milliman Care Guidelines
- Understanding and application of payer clinical medical policies
- Requires fundamental knowledge of the revenue cycle process, which includes such things as patient access, utilization review, charge capture, HIM and patient accounting.
- Requires the advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation and identify variances in standards of care.
- Requires knowledge of rules and regulations pertaining to hospital reimbursement.
- Requires familiarity with managed care principles and an understanding of post-acute continuum of care.
- Requires the interpersonal skills necessary to maintain effective working relationships and interact effectively with staff, physicians, review agencies, insurance companies, patients and patients' families.
- Requires the effective communication skills (both verbal and written) necessary to prepare documentation, write appeal letters and to provide education to staff and physicians regarding the revenue cycle process.
1. Bachelor of Science Degree or a licensed registered nurse with equivalent relevant experience
2. Current licensure in Massachusetts as a Registered Nurse in good standing.
1. Five+ years in Quality, Utilization Review, and/or Case Management.
2. Excellent written skills
3. Effective verbal communication
4. Computer knowledge including data entry, and use of an excel spread sheet