Job Description
Overview
Under general supervision, this position is responsible for the receipt, investigation and creation of the data record for medical necessity audits and denials. Reviews referrals for appropriateness and gathers information necessary for assigning appeal to appropriate clinical team. Contacts vendors, insurance companies, and other departments regarding appeal status and utilization review activity. Coordinates the preparation and posting of appeal packets.
Key Responsibilities
- Create and update denial tracking records consistently and thoroughly throughout the appeals process.
- Research denials to obtain a complete and accurate picture of the payer’s evaluation and what led to a denial.
- Proactively seek out denial correspondence that originates from various sources both internal and external to the Central Business Office (CBO).
- Appropriately assigns denials to clinical team.
- Prints medical record, scans correspondence and prepares appeal packet.
- Establishes and maintains communication with immediate team, CBO team, affiliate hospital’s UR department, vendors and payers to assist in resolving issues impacting appeals and recovery of denied revenue.
- Shares information with the team and leadership to ensure the integrity of the denial information, identify performance improvement opportunities and supports the clinical teams’ ability to prioritize, triage and overturn denials.