FREE ACCESS
5,000–10,000 jobs/day
See all jobs on JobTailor
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Clinical Appeals Analyst
PAM Health. Review patient medical records and utilize clinical and regulatory knowledge and skills to determine why cases/claims are denied and complete an appeal .
About the role
Key responsibilities & impact- Review patient medical records and utilize clinical and regulatory knowledge and skills to determine why cases/claims are denied and complete an appeal
- Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments
- Prepare convincing appeal arguments using pre-existing criteria sets and/or clinical evidence to prepare for an administrative law judge hearing and participate in hearings by providing testimony
- Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable
- Prepare data and analytics and share with the Director and Executive Team and provide feedback to hospitals regarding trends in denied claims
- Discuss documentation-related and level of care decisions with hospitals
Requirements
What you’ll need- Five years’ experience as a clinical nurse in an acute care setting
- Current state-issued RN license
- Significant experience in the healthcare field including a minimum of five years as a clinical nurse, Social Worker, or PTA in an acute care setting
- At least two to three years of experience in case management, discharge planning, and/or utilization review is preferred
- Knowledge of regulatory and payer requirements for reimbursement and reasons for denials by auditors
- Knowledge in areas such as InterQual Level of Care and Milliman & Robertson criteria
- Knowledge of third party payer regulations related to utilization and quality review is preferred
- Knowledge of MAC, RAC, ZPIC denials and process
- Ability to travel as required
Benefits
Comp & perks- Generous paid benefit time
- Excellent insurance options
- Education Advancement Program
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical knowledgeregulatory knowledgecase managementdischarge planningutilization reviewdata analyticsappeal arguments preparationclinical evidence evaluationInterQual Level of CareMilliman & Robertson criteria
Soft Skills
communicationanalytical thinkingproblem-solvingtestimony preparationcollaborationfeedback provisiondocumentation skills
Certifications
RN license