Clinical Appeals Specialist - Remote

Overview

The Clinical Appeals Specialist is responsible for managing client medical necessity denials for multiple service lines by conducting comprehensive analytic reviews of clinical documentation to determine if an appeal is warranted.

In Short

• Manage client medical necessity denials for various service lines.
• Conduct analytic reviews of clinical documentation.
• Write compelling factual arguments for appeals.
• Handle audit-related correspondence.
• Ensure compliance with state and federal guidelines.
• Interact with multiple departments to resolve grievances.
• Prepare arguments for Administrative Law Judge hearings.
• Maintain confidentiality of patient data.
• Work independently in a home-based environment.
• Adapt quickly to changing priorities.

Requirements

• Minimum five years of experience in healthcare.
• Two to three years of experience in case management preferred.
• Knowledge of regulatory and payer requirements.
• Ability to evaluate patient medical records critically.
• Skill in writing convincing appeals arguments.
• Proficient in reading handwritten medical records.
• Excellent oral and technical writing skills.
• Ability to maintain confidentiality according to HIPAA regulations.
• Flexibility and willingness to learn.
• Ability to work independently and adapt to changes.

Benefits

• 401(k) plan.
• Healthcare benefits.
• Vacation and sick days.
• Employee referral program.
• Employee discounts.
• Continuing education programs.
• Weekly training opportunities.
• Advancement opportunities within the organization.