Clinical Appeal & Audit Coordinator

Practice Area healthcare/nursing
Job Family Nursing
Job Type Perm Salary
Location Metrowest Boston


Do you possess outstanding leadership skills, as well as excellent verbal communication and interpersonal skills? Are you extremely organized and able to work in a fast-paced environment? If so, this Appeals & Audit Coordinator position is perfect for you! Submit your resume to apply today.

Responsibilities:

  • Apply the appeal process by analyzing medical records
  • Administers the hospital’s protocol criteria to create an appeal letter to affirm the medical necessity findings for the inpatient admission
  • Produces an appeal letter containing the fundamental clinical documentation for various levels of care in both inpatient and outpatient cases
  • Observes the difference between inpatient and outpatient services
  • Obtains copies of patient’s medical records as needed
  • Reviews the case as needed with case management and/or the attending physician
  • Presents an appeal packet, including all required supporting documentation, to the insurer within the contractual timeframes and submits a second appeal when necessary
  • Collaborates with the physician to obtain their letter of appeal to insurer
  • Progresses, maintains and supervises cases using an internal tracking system
  • Recognizes and regulates any issues on monthly summaries
  • Utilizes supporting internal applications for documenting
  • Reviews account information in billing system, records for off-site audit, and insurer contracts as needed to verify accuracy and identify potential issues
  • Consults with other disciplines as needed for clarification or retrieval of documentation
  • Using audit tracking tool, monitor audit activity and analyze trends
  • Working knowledge of the audit and patient denial process

Requirements:

  • Knowledge of insurance state and federal regulations
  • Exceptional written skills
  • Proficiency in computer skills such as data entry and Microsoft Excel
  • Bachelor of Science degree or a licensed RN with related experience
  • 3-5 years’ experience using Case Management in an acute care setting/managed care environment

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Position ID: 38612