Clinical Denials and Appeals RN

📋 Description

• • Conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence-based criteria such as InterQual and Milliman Care Guidelines.
• • Perform retrospective medical record reviews to validate completeness and accuracy of physician and clinical documentation supporting level of care and services rendered.
• • Identify root causes of claim denials and determine appeal viability based on payer policies, regulatory guidance, and clinical standards.
• • Prepare, submit, and track clinical appeals, including drafting written appeals for payer reconsideration.
• • Collaborate with Patient Access, Case Management, Utilization Management, Coding, and Mid-Revenue Cycle teams to resolve denials and implement preventive measures.
• • Research and apply payer-specific policies, CMS regulations, and contractual language to strengthen appeal arguments.
• • Track and report denial and appeal outcomes, identify trends, and provide actionable recommendations for process improvement and staff education.
• • Maintain accurate, compliant documentation of all review activities in hospital and payer systems according to regulatory and organizational standards.
• • Utilize clinical expertise to interpret complex medical records and align documentation with reimbursement requirements.
• • Ensure adherence to federal and state healthcare regulations in all denial and appeals activities.
• • Support revenue cycle integrity by reducing avoidable denials through proactive clinical documentation review and education.
• • Work independently to manage multiple concurrent cases with high attention to detail and deadlines.
• • Apply knowledge of hospital revenue cycle workflows, medical necessity criteria, and payer rules to optimize appeal success rates.
• • Communicate findings and recommendations clearly in writing to cross-functional teams and leadership.
• • Stay current with evolving Medicare, Medicaid, and commercial payer guidelines affecting clinical denials and appeals processes.