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Clinical Appeals - Denials Specialist

Phoenix, AZ
Clinical Appeals - Denials Specialist
Phoenix AZ

Duties and Responsibilities:
• Maintain ownership and responsibility for assigned accounts.
• Maintain working knowledge of applicable health insurers’ internal claims, appeals, and retro-authorization timely filing deadlines and processes.
• Review clinical denials including but not limited to referral, pre-authorization, medical necessity, non-covered services, investigational/experimental and billing resulting in denials and/or delays in payment.
• Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and third-party guidelines.
• Medical Necessity Reviews are based on InterQual, Milliman Clinical Guidelines (MCG), Medicare guidelines, and health insurer-specific guidelines.
• Review retro-authorizations in accordance with health insurer requirements and follow insurer process guidelines
• Identify denial patterns with client to mitigate risk and minimize regulatory penalties
• Escalate potential risks to client, client partners and/or leadership

• Additional Duties
• Adherence to all Cognizant policy and procedures.
• Compliance with HIPAA regulations
• Report all breaches to Corporate Security
• Maintain security of all client-issued and client-issued credentials (e.g., usernames, passwords, access).
• Perform additional duties as assigned.

Special Skills 
• Ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads 
• Ability to troubleshoot basic IT problems 
• Intermediate knowledge of Windows operating system 
• Intermediate Microsoft Office Products, such as: Word, Excel, Outlook & PowerPoint skills 
• Excellent -critical thinking/ clinical judgement; and problem-solving skills 
• Knowledge of vendor/client relationships and organizational structure 
• Ability to cross reference all mandatory guidelines that pertain to the case and/or payer source 
• Strong verbal and written communication skills with external and internal customers 
• Identify and communicate potential risks in process/platform irregularities to leadership utilizing escalation 

Matrix Minimum Qualifications: 
• Current Active and Unrestricted Registered Nursing License required (Associate Degree, Nursing Diploma or Bachelor’s degree in Nursing) 
• NCLAX License is required from any state.
• Intermediate typing skills: Minimum of 40 word per 

Preferred Qualifications: 
• 3-5 years combined clinical and/or utilization management experience with managed health care plan 
• 3 years of experience in health care revenue cycle or clinic operations role 
• Knowledge and application of managing and appealing denials 
• Experience in medical and insurance terminology, CPT, ICD coding structures, and billing forms (UB, 1500) 
• Experience and application of InterQual and/or Milliman Care Guidelines (MCG) 
• Knowledge of Medicare, Medicaid and third-party reimbursement methodologies 
• Effective communication skills both oral and written

Sweta N
Sr. Technical Recruiter
Reqroute Inc,
Email: Sweta@reqroute.com
Phone: 408-600-2007 Extn: 1015
Companies across U.S. have engaged ReqRoute, Inc to deliver skilled, dedicated IT professionals. Recruiting is our passion and we support Fortune 1000 companies with their hiring needs. We always seek to deliver competitive and sought-after career opportunities to our potential consultants and employees. We invite you to review the position requirements and apply today if your skills match our needs.  
ReqRoute, Inc is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, disability, military status, national origin or any other characteristic protected under federal, state, or applicable local law. (www.reqroute.com)

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