Clinical Appeals Consultant
| Company | Intermountain Healthcare |
|---|---|
| Location | West Valley City, UT, USA |
| Salary | $39.99 – $59.18 |
| Type | Full-Time |
| Degrees | Bachelor’s, Associate’s |
| Experience Level | Mid Level |
Requirements
- Graduate of an accredited school of nursing is required (Associates or Bachelor’s degree)
- Current valid RN License is required
- Three (3) years experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting required.
Responsibilities
- Uses nationally recognized evidence-based utilization review criteria to assess and write up clinical reviews for insurance audits and governmental insurance appeals using supporting documentation.
- Assesses the appropriateness of clinical appeal requests by using payer policies and Federal and State regulations.
- Works with Physician Advisors to obtain clinical support for appeals if needed.
- Collaborates with Care Management, Utilization Review, Physician Advisors, Revenue Integrity, Compliance, Legal Counsel and the RCO teams to prepare appeals.
- Identifies trends and works with the appropriate multidisciplinary teams to improve denial management, documentation and appeals processes.
- Supports and works with legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process.
Preferred Qualifications
- Bachelor’s or Master’s degree in nursing (BSN or MSN) is preferred.
- Five (5) years experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting required.