Job description

Appeals Case Manager

Support Department: Case Management

Salary Range: $54.19 - $85.45 Hourly

Management: No

Schedule: FT 09:00 AM -17:30 PM

Reports To: Director of Case Management

Summary: Manage medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Write sound, compelling factual arguments to appeal the claim. Track and trend data to identify any systemic issues causing denials and follow up appropriately to resolve such issues. Develop and implement training tools to educate Physicians, CM, and staff, on reasons for denials, proper coding, and clinical documentation to prevent denials. Review patient medical records and appeal those cases where Medical necessity is present. Follow up on clinical denials and timely appeals submission. Ensure that the papers are prepared to reimburse for scheduled services in accordance with the payer-provider contract, and work diligently toward the identification, mitigation, and prevention of clinical denials. Uses clinical expertise while reviewing medical necessity, responding to authorization concerns, and/or reconciling coverage-related issues.

Requirements: Maintain an active California RN license preferred. Bachelor's degree in Nursing, Business, Health Care Administration, or related field. Minimum two (2) years of acute hospital experience preferred. 2 years of recent Hospital Denials Management, Case Management, Chart Audit experience, or equivalent preferred. Clinical Documentation Review experience preferred. Strong analytical skills and understanding of business processes. Excellent communication and customer service skills. Organized with special attention to detail. Excellent verbal, written, and organizational skills are required. Knowledge of medical terminology and current third-party payor reimbursement methodologies. Ability to follow the chain of command. Self-motivated, proactive, and results-oriented. Must be able to demonstrate sound decision-making and prioritization skills, and utilizes the approved process to resolve biophysical, psychological, educational, and environmental needs of patient/significant others when administering or explaining care. Proficiency with main-frame and personal computers. Proficient use of all Microsoft Office suite software.

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