Clinical Appeals Author (E)

Clinical Appeals Author (E)

Summary : The Clinical Appeals - Author performs appeals and denials management and represents the hospital where claims were denied by either governmental contractors or commercial payers. Completes comprehensive reviews of clinical documentation to determine if an appeal is warranted. Writes compelling clinically relevant letter that includes payer guidelines to support the medical necessity for the stay to be paid at the level that was billed. Handles audit-related correspondence and other administrative duties as required.

Education / Licensure : Medical Graduate, Physician Assistant or Registered Nurse (Current RI License)

Experience :

• Knowledge of third-party payer regulations
• One (1) year of previous appeals / denials experience
• Knowledge in areas such as InterQual Level of Care Criteria and Milliman Criteria

Skills and Abilities :

Working Conditions, Physical Environment and / or Safety Requirements :

Visual acuity and hand dexterity. Physical ability involves variety of body movements including stooping, bending,

kneeling, lifting, standing, walking, twisting, stretching and reaching. Physical ability involves pushing, pulling

and lifting more than 30 lbs.

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