Clinical Utilization Review & Appeals Coordinator

Job Description

The Clinical Utilization Review and Appeals Coordinator combines clinical, business and regulatory knowledge and skill to reduce financial risk and exposure caused by concurrent and retrospective denial of payment for services provided.  

Reviews and validates admission status of surgical admissions, verifies procedure against the Inpatient Only List and Inter-Qual Criteria, educates Physicians and facilitates obtaining the correct admission status, ensure that the appropriate notification letters are issued, reviews concurrent denials and provides insurance reviews, serves as an Inter-Qual resource to staff, provides oversight and compliance of the Observation status process, ensures compliance with the 2-midnight rule. 

Pursues, analyzes and remains up to date on data regarding all medical necessity denials.  Collaborates with physicians, case managers, Hospital Billing Office staff and payers to appeal denials.  Insures a functional denial appeals process, including measuring denial and appeal activity, monitoring for patterns and trends, and reporting the outcomes of these activities as requested.

Serves as the central point person for all commercial and government claim recovery activities providing efficient management of work flow related to MediCal, commercial denial/appeal and Recovery Audit activities.

Provides guidance, support and oversight to ensure effective management of the audit response process.

Facilitates all aspects  of the denial/appeal process which include maintaining database, tracking and trending denials, and reporting  process outcomes.

Qualifications

Bachelor of Science in Nursing

Five (5) years’ experience in hospital admission appeals, case management, or clinical documentation improvement.

Experience with program development and strong working knowledge of federal government regulations with specific focus on Medicare and Medicaid reimbursement. 

Proficient in database management.

Familiar with reviewing procedural documentation areas in electronic health record.

Highly collaborative and able to work cohesively in a dynamic team environment; strong interpersonal and professional skills.

Strong data processing and analytical skills, accompanied by strong critical thinking skills and an aptitude for conducting thorough research

License/Certification/Registration Requirements

Current registration in the State of California as a Registered Nurse

Salary Range:

$82.01 - $123.02 USD Hourly