Clinical Appeals - Author at Alta Hospitals System Corporate/CBO in Los Angeles, California

Job Description:

Clinical Appeals - Author (Remote)

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Clinical Appeals - Author performs appeals and denials management and represents the hospital where claims were denied by either governmental contractors or commercial payers. Completes comprehensive reviews of clinical documentation to determine if an appeal is warranted. Writes compelling clinically relevant letter that includes payer guidelines to support the medical necessity for the stay to be paid at the level that was billed. Handles audit-related correspondence and other administrative duties as required.

Job Responsibilities/Duties

• Reads, understands and abstracts information from patient medical records in electronic and scanned paper formats within an EMR, meeting all department productivity goals, for identified payor populations as directed.
• Utilizes clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied. Identifies risk factors, comorbidities and adverse events to determine if payer denial was justified and an appeal is required.
• Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments. Prepares convincing appeal arguments, using pre-existing payer criteria sets and/or clinical evidence from existing library of clinical references.
• Performs duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, and all regulatory agencies, including State and Federal. Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
• Researches medical literature and evidence based medical publications to support the level of care provided.
• Reviews/audits patient claims with medical necessity denials looking for patterns by services or by the ordering physician. Follow-up in improving clinical documentation to reduce such denials. Works collaboratively with health information management coding staff, physicians and financial services to resolve payment denials and documentation issues. Performs other administrative duties as needed/assigned.

Minimum Education: Medical Graduate, Physician Assistant or Registered Nurse (Current CA License) Required

Minimum Experience: Ability to effectively communicate with staff, including physicians, in a clear and concise manner Required. Knowledge of third-party payer regulations Preferred. One (1) year of previous appeals/denials experience Preferred. Knowledge in areas such as InterQual Level of Care Criteria and Milliman Criteria Preferred.

Req. Certification/Licensure: Medical Graduate, Physician Assistant or Registered Nurse (Current CA License) Required

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm

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