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Clinical Reviewer-Clinical/Reimbursement Denials & Appeals

Company: Health Resources Optimization
Location: Hempstead
Posted on: January 12, 2022

Job Description:

Position Summary - - -The Clinical Reviewer is responsible for reviewing documentation related to denials and making clinical determinations, then preparing written appeals supporting payment of denial reconsiderations. -This position applies both clinical knowledge and technical knowledge of medical necessity and DRG coding. Strong oral, written and interpersonal communication skills are required. Must be detail oriented with strong organizational and analytical skills. Must work well within a dynamic team-based environment and have a positive attitude. Prior inpatient acute care hospital level experience is required. Revenue Cycle, Certified DRG Coding Credentials or CDI/DRG coding experience a plus, but will train the right candidate. Candidates must have broad-based, up to date clinical knowledge. Must be available for training in our NY office for up to 4 weeks prior initiating remote work. The ideal candidate resides in the tristate area (NY, NJ, CT). - -
Essential Duties & Responsibilities

  • - - - - - - - - -The Clinical Reviewer is directly responsible for reviewing denials & client facility Medical Records (MR's) for a variety of facility required reviews, including medical necessity, documentation and coding.
  • - - - - - - - - -Performs a comprehensive, retrospective medical record reviews and identifies information present to support the services rendered -
  • - - - - - - - - -Researches evidence-based practices and utilizes application of regulatory policies to support clinical appeal.
  • - - - - - - - - -Creates a concise medical summary and clinical argument within each appeal based on support from the medical record and evidenced based sources
  • - - - - - - - - -Identifies process gaps and trends to support client facility quality improvement
  • - - - - - - - - -Participates as a Hospital advocate for telephone Medicare (ALJ) hearings to facilitate denial resolution
  • - - - - - - - - -Provides clinical review support to Arbitration/Litigation actions as required
    Skills
    • - - - - - - - - -Attention to detail, strong organizational skills and self-motivated.
    • - - - - - - - - -Ability to independently & accurately make decisions and assimilate multiple data sources or issues related to problem solving.
    • - - - - - - - - -Ability to work under a timeline/deadline, prioritize work and maintain accurate records of completed work
    • - - - - - - - - -Strong Computer skills and Data Literacy
    • - - - - - - - - -Competent in Microsoft office including Excel
    • - - - - - - - - -Excellent English Language Communication skills - both written and verbal
    • Knowledge of Medicare or Medicaid regulations
    • Knowledge of CPT/HCPCS and ICD codes preferred
      Qualifications
      • Minimum 3 years clinical experience in an acute care setting
      • Current RN license or other professional license
      • Foreign Medical Graduates, Certified Coders and Advanced Medical/PA students also eligible
      • CCS, RHIA, CRC, CIC, CDI experience preferred; candidate will be expected to pursue credentialing after hire

Keywords: Health Resources Optimization, Hempstead , Clinical Reviewer-Clinical/Reimbursement Denials & Appeals, Healthcare , Hempstead, New York

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