Clinical Appeals - Denials Specialist
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.
• 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
• 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
Sr. Technical Recruiter
Phone: 408-600-2007 Extn: 1015