Clinical Appeals Specialist
US-ID-Twin Falls
careers
Req #: 101760
Type: Full-Time
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Overview: At St. Luke's, we pride ourselves on fostering a workplace culture that values diversity, promotes collaboration, and prioritizes employee well-being. Our commitment to excellence in patient care extends to creating an environment where our team can thrive both personally and professionally. With opportunities for growth, competitive benefits, and a supportive community of colleagues, St. Luke's is truly a great place to work. What You Can Expect: Under limited supervision, the Clinical Appeals Specialist, is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. * Reviews patient medical records and utilizes clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required. * Prepares appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments, as necessary. * Acts as a resource to the verifiers on documentation, coding & clinical account review. * Maintains knowledge of state and federal guidelines, advisory opinions, updates, bulletins, and other communication related to the revenue cycle and provide updates to appropriate individuals in the organization. * Coordinates and integrates data from multiple sources to provide and maintain a single reporting location that reflects clinical denials and appeals activity. * Recommends improvements and modifications to departmental operating procedures to maximize operating efficiency and reimbursement. * Performs other duties and responsibilities as assigned. Qualifications: * Education: Bachelor's Degree or 7 years relevant experience in lieu of degree. * Experience: 3 year's experience. Responsibilities: Under limited supervision, the Clinical Appeals Specialist 2, is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. * Reviews patient medical records and utilizes clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required. * Prepares appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments, as necessary. * Acts as a resource to the verifiers on documentation, coding & clinical account review. * Maintains knowledge of state and federal guidelines, advisory opinions, updates, bulletins, and other communication related to the revenue cycle and provide updates to appropriate individuals in the organization. * Coordinates and integrates data from multiple sources to provide and maintain a single reporting location that reflects clinical denials and appeals activity. * Recommends improvements and modifications to departmental operating procedures to maximize operating efficiency and reimbursement. * Performs other duties and responsibilities as assigned. Qualifications: * Education: Bachelor's Degree * Experience: 3 year's experience.
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