COMPANY BENEFITS

20 Paid Time Off (PTO) per year
Annual Appraisal
Quarter Incentive
Weekends off
HMO with FREE 2 dependents
Group life insurance

SUMMARY

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.

JOB DUTIES & RESPONSIBILITIES

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.

QUALIFICATIONS

Required:

Minimum of 1-year Medical Necessity Appeals Writing experience in a provider or payor setting
Medical-surgical/critical care experience; managed care payor experience either in Utilization Review, Case Management or Appeal; Minimum of 1-year recent acute care experience in a facility environment
Preferably possess a valid nursing license, advanced medical degree such as Occupational Therapy (O.T.), Physical Therapy (P,T.) or Medical Doctor (M.D.) with previous appeal writing experience.
Current, valid RN licensure; Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM)

Working Conditions:

Office work arrangement
Amenable to work in BGC, Taguig
Dayshift schedule

Clinical Denials Clinician

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