Clinical Appeals Job Description

Clinical Appeals Job Description

4.8
164 votes for Clinical Appeals
Clinical appeals provides administrative direction to the research support of the department; in collaboration with the Chair, ensures compliance with institutional guidelines and state and federal laws.

Clinical Appeals Duties & Responsibilities

To write an effective clinical appeals job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical appeals job description templates that you can modify and use.

Sample responsibilities for this position include:

Understand and communicate contract specific issues related to the resolution of disputed payments, discount and allowance calculations for a variety of payers such as Medicare, Medicaid, HMO’s, PPO’s, IPA’s, employers
Maintain established departmental policies and procedures, objectives, patient, and customer service policies
Handle difficult patient and third party follow-up problems
Review accounts recommended for write-off to ensure accounts have aged as determined by corporate/guidelines
Review accounts in bankruptcy
Review agency and attorney performance reports
Assist team members with questions, concerns, and complaints from insurance companies, patients, and other personnel
Work as a liaison between team members and PAS staff
Assist with payroll activities for team members (i.e., time cards, edit sheets)
Establish working relationships with individuals at insurance companies

Clinical Appeals Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Clinical Appeals

List any licenses or certifications required by the position: MCG, CPC, FEMA, NCCPA, CCM

Education for Clinical Appeals

Typically a job would require a certain level of education.

Employers hiring for the clinical appeals job most commonly would prefer for their future employee to have a relevant degree such as Associate and Master's Degree in Nursing, Health, Healthcare, Therapy, Education, Associates, School of Nursing, Management, Graduate, Health Services

Skills for Clinical Appeals

Desired skills for clinical appeals include:

Community
State and federal laws and resources
Experience with CPT and ICD-9 coding
Medical terminology
Individual judgment and experience to assess the appropriateness of service provided
Length of stay and level of care
Relevant and applicable Federal and State regulatory requirements and guidelines
Medicaid
Hospital department computer systems
Milliman and CMS

Desired experience for clinical appeals includes:

Assist manager with developing team goals and action plans
Identifies problem accounts and escalates as appropriate
Works with guarantors to secure payment on account balances denied for clinical reasons
Assists with payroll activities for team members (i.e., time cards, edit sheets)
Medical Coding or CDI experience
Gather complex clinical information, coverage policy and criteria information and work within regulatory guidelines to make coverage recommendations

Clinical Appeals Examples

1

Clinical Appeals Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of clinical appeals. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical appeals
  • Participants satisfactorily complete field training assignments, within a hospital and PAS back office setting, specifically designed to perfect management, analytical and technical skills within areas listed in the “Job Summary” section above
  • During the program, participants may serve as interim manager or director within various facilities and/or functions to further enhance their management and technical skills
  • Identify coding or billing problems from EOBs and work to correct the errors in a timely manner
  • Work with patients and guarantors to secure payment on outstanding account balances
  • Oversee the activities and management related to Government and Managed Care appeals/denials, ensuring processes are performed efficiently and effectively
  • Mandatory root cause analysis of denials and work collaboratively with Prebill Denials Director to understand root cause and trends to decrease new denials and final write off denials by identifying operational opportunities that will decrease denials overall, such as contract language, patient access process changes, case management collaboration, appeal opportunities
  • Provide support and guidance related to the Denials Management Action Teams (DMAT)
  • Monitoring, trending and communicating with SSC Leadership, Case Management Director’s, Denials Managers, and Facility Leadership regarding denial trends, new denials and final write off denials identified via EDW, Vista, and other denials tools reports
  • Must demonstrate strong commitment to stakeholder relationships by taking ownership of issues and facilitating effective outcomes in a timely manner
  • Oversee management of Denials personnel, providing recommendations for hiring, promotion, salary adjustment and personnel action where appropriate
Qualifications for clinical appeals
  • Minimum 1 year of experience working as a Pharmacist
  • Experience using online clinical references and accessing professional (clinical and regulatory) internet sites
  • Experience working with onscreen document images
  • Intermediate computer proficiency with MS Office and must have the ability to navigate a Windows based environment
  • Participating in overtime as required based on business needs
  • Requires extended periods of standing, walking, sitting and carrying up to 25 pounds
2

Clinical Appeals Job Description

Job Description Example
Our company is growing rapidly and is looking to fill the role of clinical appeals. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical appeals
  • Establish controls and review mechanisms for PAS policies and procedures
  • Monitor trends and communicate significant shifts in market or operating conditions to PAS and facility leadership
  • Identify and implement process improvements improve services to facility customers
  • Chairperson of National Pacific Dental QIC
  • Member of the National CAC
  • Chairperson of the National Peer Review Committee
  • Chairperson or Member of the National Credentialing Committee
  • Member of the National Clinical Policy and Technology Committee
  • Pursue additional payment on open appeals through various mean of communication with payers and patients
  • Overcome objections that prevent payment of the claim
Qualifications for clinical appeals
  • Commercial benefit experience
  • Prepares all cases for review by the Physician Reviewer/Nurse Reviewer and completes all correspondence related to initial or reconsideration determinations (factual and medical necessity)
  • Receive, compile, review and mailing of letters for the non covered benefit, AOR (appoint of representative), over 90 day, and miscellaneous correspondence and documents activity in MSR
  • Update letter templates as TRICARE policy change orders are received and effective date is established
  • Researches MSR, TMCS, claims system, and TRICARE Manuals (Policy,Reimbursement and Operation Manuals)
  • Responsible for tracking each case assigned to them from receipt until completion
3

Clinical Appeals Job Description

Job Description Example
Our innovative and growing company is hiring for a clinical appeals. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical appeals
  • Utilize effective documentation that support a strong historical record of actions taken on the account
  • Provides introductory and ongoing training and education to all Appeals staff to ensure that policies and procedures are followed
  • Assists with staff communication, providing updates, resolving issues, setting goals and maintaining standards, including performing QA reviews for staff
  • Assists with payroll activities for team members
  • Identifies problem accounts and/or trended issues and escalates as appropriate
  • Ability to perform basic math calculations, to ensure accurate statement of accounts receivable
  • Ability to punctuate properly, spell correctly and transcribe accurately
  • Pursue additional payment on open appeals through various means of communication, such as telephonically, online or via payment package processes with payers and patients
  • Escalate accounts to appropriate individuals at the payer and via SSC management as needed, including accounts with lack of timely payer response
  • Utilize computer programs and software to ensure assigned cases are tracked and monitored in an efficient and effective manner
Qualifications for clinical appeals
  • PBM, managed care or health plan operations experience
  • Responsible for Liberty processes including retrieval of faxed requests, documentation, and scanning of hard copy documents
  • Receives and compiles responses to inquiries from TMA/NQMC, including authorization information, claim information and medical records
  • Assist external and internal customers (beneficiaries, providers, and associates) with inquiries regarding the denial/reconsideration/appeal process and documents all activity in MSR
  • Maintain current knowledge of the TRICARE/Champus program as evidenced by
  • Researches MSR, TMCS, Claims system, and TRICARE Manual(Policy, Reimbursement, and Operation)
4

Clinical Appeals Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of clinical appeals. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical appeals
  • Identify contract protection that can be leverages to overturn denials
  • Perform basic math to ensure accurate statement of accounts receivable
  • Creates Peer Advisor reviews in the system
  • Generates detailed adverse determination and appeal determination letters conforming to regulatory, accreditation, and client requirements
  • Receives and documents inquiries from providers and members and informs parties of final decisions made
  • Provides on-call adverse determination and appeal determination letters during weekends and holidays
  • Supports the Peer Advisor work flow and contractual requirements designated within specific Service Centers supported by National Peer Advisor Services
  • Initiates the appeal process, at the direction of the Supervisor and/or physician advisors, until the case is overturned, appeal options are exhausted or decision is made to discontinue process
  • Coordinates all utilization review functions, including response to payor requests for retrospective review information including Medicare and MediCal regulations/requirements
  • Manage daily activities related to PAS Clinical Appeals function, ensuring processes are performed
Qualifications for clinical appeals
  • Assist Manager and/or Supervisor with special projects as assigned
  • Good communication Skills- written, telephonic, face to face
  • Professionalism in interactions (governmental agencies, quality monitoring)
  • Previous experience in medical records review/appeals procedure
  • Clinical Skills – ability to read and interpret medical records preferred
  • Current, valid RN licensure
5

Clinical Appeals Job Description

Job Description Example
Our company is growing rapidly and is hiring for a clinical appeals. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical appeals
  • Assign cases to Clinical Appeals Nurse staff (30) for the production of written clinical appeals
  • Provide clinical support for producing high quality, timely, and effectively written clinical appeals
  • Evaluates performance and holds the team accountable
  • Inspires high performance and production
  • Provides leadership to and is accountable for the performance of the team
  • Interfaces with broad range of related entities associated with commercial insurance denials
  • Office setting job working as an appeals clinical pharmacists performing clinical case review of appeal coverage determination requests
  • Ensures that appeals and grievances are properly classified
  • Processes appeals and grievances within NYS and federal regulatory time frames, which could be standard (long period time) or expedited (3 day turnaround)
  • Handles appeals and grievances in accordance with internal company policy which includes entering data into appropriate medical management systems
Qualifications for clinical appeals
  • Experience with insurance denials and ability to compose clear and concise appeal letters to payers is required
  • Medical doctor’s office experience and/or medical insurance experience strongly preferred
  • Strong ability to work independently meet daily work goals
  • Candidates must be able to work Monday through Friday from 9 AM to 6 PM, with occasional overtime
  • Minimum one year experience in related area required
  • The ability to read and interpret medical records preferred

Related Job Descriptions

Resume Builder

Create a Resume in Minutes with Professional Resume Templates