Clinical Appeals Specialist

Summary

Join Discovery Behavioral Health as a Clinical Appeals Specialist and manage client medical necessity denials for various service lines. You will conduct comprehensive reviews of clinical documentation, write compelling appeal arguments, and handle audit-related correspondence. This is a full-time remote position offering competitive compensation and a comprehensive benefits package. You will collaborate with various departments to resolve grievances and ensure compliance with regulations. The ideal candidate possesses significant healthcare experience, including clinical nursing or therapy, and strong analytical and writing skills. Discovery Behavioral Health is committed to diversity and inclusion, encouraging applications from individuals who may not meet all qualifications.

Requirements

• Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse or therapist
• Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by auditors
• Ability to critically evaluate and make decisions about whether appeals should be made based on reviews of patient medical records
• Skill in writing convincing appeals arguments that are sound and supported by evidence that is related to patients’ specific clinical attributes
• Ability to use pre-existing criteria sets and/or clinical evidence from an existing library of clinical references and/or regulatory arguments to support one’s own clinical appeals arguments
• Ability to search for supporting clinical evidence to support appeal arguments when there are not existing resources available
• Demonstrated ability to prepare arguments for an Administrative Law Judge Hearing and participate in a hearing
• Ability to proficiently read, understand, and abstract information from handwritten patient medical records are essential prerequisites
• Ability to work in a home-based environment and to work independently as an individual contributor and adapt quickly to changing priorities
• Maintains confidentiality of patient data and medical records in compliance with HIPAA regulations
• Ability to read, evaluate, and abstract important information from handwritten patient medical records
• Excellent oral and technical writing and typing skills
• Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and task-related priorities
• Ability to successfully work independently and to adapt quickly to changing priorities and regulations. Excellent oral and technical writing skills and the Ability to maintain confidentiality according to HIPAA regulations is required

Responsibilities

• Review patient medical records and utilize 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
• Logs, tracks, and processes appeals and grievances. Conducts pertinent research in order to evaluate, respond to, and close appeals. Builds case files for each grievance and ensures compliance with organizational and regulatory guidelines
• Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments
• Interact with Supervisors, Manager, Medical Directors, Case Management, Precertification, Legal, Member Services and other departments in facilitating identification and resolution of grievances
• Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments
• Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable
• Discuss documentation-related and level of care decisions as required
• Proficiently read and understand abstract information from handwritten patient medical records
• Ensure compliance with HIPAA regulations, to include confidentiality, as required
• Responsible for compliance with all regulatory and department timelines
• Must be able to organize, plan and implement the functions of Member Appeals and Grievances, maintain timelines and turnaround times to meet multiple requirements/regulations established by external regulating bodies and applicable state and federal laws
• Requires ability to understand and be compliant with State and Federal regulations

Preferred Qualifications

In addition, having at least two to three years of experience in case management, discharge planning, and/or utilization review is preferred

Benefits

• 401(k)
• Healthcare benefits
• Vacation and sick days
• Employee referral program
• Employee discounts to various stores, amusement parks, events, etc
• Continuing education (CE) programs and training
• Weekly training opportunities
• Advancement opportunities within the organization