Specialist, Clinical Appeals

Job description

Clinical Denial Review and Analysis: - Perform comprehensive reviews of denied claims, focusing on clinical issues such as medical necessity, level of care, non-covered services, and authorization-related denials. - Conduct thorough analysis of patient medical records, payer medical policies, and relevant medical necessity criteria (e.g., InterQual, Milliman) to build a robust clinical case for appeal. - Identify gaps in clinical documentation and collaborate with other team members to gather the necessary supporting evidence for a successful appeal. Appeal Generation and Submission: - Independently write professional, persuasive appeal letters that present a compelling clinical argument for payment. - Leverage generative AI tools to assist in drafting initial appeal letters, increasing efficiency and allowing focus on the most complex cases. - Ensure all appeals are submitted accurately, within payer-specific timelines, and tracked through to final resolution in the Pulse platform. Collaboration and Process Improvement: - Work closely with the Payer Contract Specialist, Certified Coders, and Revenue Recovery Specialists to ensure a holistic and coordinated approach to each appeal....