Appeals Reviewer Veteran Job Description Samples

Results for the star of Appeals Reviewer Veteran

Coding/Medical Review And Appeals RN

The Coding/Medical Review and Appeals Registered Nurse is responsible for reviewing medical records to facilitate proper professional and/or facility coding of assigned specialties performed within the Marshfield Clinic Health System (MCHS). This individual acts as a liaison in providing accurate and timely information/guidance to physicians, allied providers, managers, and staff in regard to various coding and/or Medicare/Medicaid policy issues. The Coding/Medical Review and Appeals Registered Nurse is responsible for the initial development of payor or Recovery Audit Contractors (RAC) appeals correspondence materials.

Marshfield Clinic Health System is committed to enriching the lives of others through accessible, affordable compassionate healthcare. Successful applicants will listen, serve and put the needs of patients and customers first.

Company:

Marshfield Clinics

ReqNumber:

MC171034

Location: Marshfield, WI



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Appeal Nurse Reviewer

Appeal Nurse Reviewer Responsibilities

  • Investigate and resolve medical appeals for health plan members in both Medicare and Medicaid plans
  • Participate in departmental audits and regulatory site visits

Appeal Nurse Reviewer Job Requirements

  • BSN and RN (specifically in Illinois)
  • 3-5 years' experience in a clinical setting
  • Working knowledge of Milliman, InterQual, and / or Apollo
  • Experience with Medicare / Medicaid
  • Experience in a managed care environment

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Rehab Appeals Specialist

Must be a PTA or COTA General Purpose: Assist the Director of Rehab Compliance with day to day paper flow involving ADR’s/Medicare audits, etc.

Essential Job Functions This Company expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents. Therefore, the following list of duties is not all-inclusive: Communicate additional development requests and denials to each facility, as well as the rehab providers.

Work in conjunction with the Nursing Appeals Specialist to ensure the medical record documentation supports the services billed, identify additional documentation needed to complete the request. Determine additional education and training needed by each facility to ensure any issues are corrected to avoid future denials. Assist in maintain and tracking of information in esolutions or other method through the appeals process.

Follow up with facilities/ rehab providers to ensure each process is followed timely, sending reminders as necessary. Send in medical record packets and/or letters and request forms to the appropriate agency for each level using the most efficient method (i.e. scan or fax). Check the status of appeals and denials to determine the most appropriate next step. Complete rehab portion of appeal letters and audit requests to summarize information requested by reviewing agency in support of the services provided and billed.

Assist with the completion of therapy documentation audits to determine appropriate areas for additional education and training to ensure all medical records reflect the skilled services provided and billed. Other Duties as assigned. Minimum Qualifications Associate degree in Occupational or Physical Therapy Strong computer skills.

Primarily Excel and Word Excellent written and oral communication skills Outstanding interpersonal skills with a high level of energy and enthusiasm Organized and detailed in work performance Good communication skills with excellent self-discipline and patience Genuine caring for and interest in elderly and disabled people in a nursing facility Comply with the Residents’ Rights Perform work tasks within the physical demand requirements as outlined below Perform Essential Duties as outlined above Working Conditions Subject to frustrations in meeting work demands due to frequent interruptions Fast paced, required to make decisions quickly Involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances May work beyond normal duty hours, on weekends, and in other positions temporarily, when necessary Physical and Sensory Requirements Meet general health requirements set forth by the policies of this Company, which may include a medical and physical examination. EMPLOYMENT AT WILL: It is the express policy and intent of this facility that the employment relationship is one created and governed by the continuing will of both parties.

I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause by either party, unless provided otherwise by a written agreement signed by the President of this company. NONDISCRIMINATORY STATEMENT: This facility does not discriminate on the basis of race, religion, national origin, color, creed, sex, age, disability, marital or veteran status with regard to employment.



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Clinical Resource Management, Appeals Coordinator

Clinical Resource Management, Appeals Coordinator Send This Job to a Friend Department Clinical Resource Management Schedule Full Time Benefits Eligible (Nursing) - NF Shift Day Shift (1) Hours 80 Job Details GENERAL SUMMARY Responsible for coordinating and monitoring the denial management and appeals process. Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided.

Collaborates with physicians, case managers, revenue cycle personnel and payers to appeal denials. EDUCATION: Bachelor's Degree from an accredited school of nursing is required. PRIOR EXPERIENCE:

Minimum of three to five years as clinical nurse in an acute care setting. Extensive knowledge of clinical symptomotology and related treatment and hospital utilization management. Knowledge of current reimbursement models: commercial, managed care, Medicare, Public Assistance.

Technical writing ability for appeal letters and reports. CERTIFICATION/REGISTRATION/LICENSURE: Current RN license.



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Appeals Navigator

Appeals Navigator Print Apply Appeals Navigator Salary $29.51 - $35.33 Hourly Location Denver, CO Job Type Part Time Department Department of Labor and Employment Job Number KAA-AIV UI-6/17 Closing 6/26/2017 5:00 PM Mountain

  • Description

  • Benefits + Questions Department Information The Colorado Department of Labor and Employment is a values-driven organization, committed to teamwork, collaboration, accountability, adaptability, excellence, integrity and respect. We believe in outstanding customer service, an inclusive culture, continued process improvement, and in our role as a trusted and strategic partner.

    Recognizing that making our employees successful also drives our success, we are eager to invest in dedicated individuals who exhibit our shared values and our passion for quality and excellence in all we do. The work we do is rewarding and, through a variety of divisions and programs. The Colorado Department of Labor and Employment connects job seekers with great jobs, provides an up-to-date and accurate picture of the economy to help decision making, assists workers who have been injured on the job, ensures fair labor practices, helps those who have lost their jobs by providing temporary wage replacement through unemployment benefits, and protects the workplace - and Colorado communities - with a variety of consumer protection and safety programs.

    In addition to rewarding and meaningful work, we offer a variety of benefits that you simply will not find at other employers: + Strong, secure, yet flexible retirement benefits including a PERA Defined Benefit Plan or PERA Defined Contribution Plan plus 401K and 457 plans + Medical and dental health plans + Employer supplemented Health Savings Account + Paid life insurance + Short- and long-term disability coverage + 10 paid holidays per year plus vacation and sick leave + Discounted RTD EcoPass (Denver Metro locations) + BenefitHub state employee discount program + CafeWell employee wellness program + Excellent work-life programs, such as flexible schedules, training and more Our agency website: Colorado Department of Labor and Employment The State of Colorado is an equal opportunity employer. Description of Job This position is open only to Colorado state residents.

    This is a grant funded position. The current grant is from July 1, 2017 until June 30, 2018. The individual hired for this position will be required to sign a waiver of retention rights.

    The position may be extended year to year depending on the availability of funds. This part-time position is eligible for State of Colorado benefits. This purpose of this position is to provide guidance to employers regarding worker classification.

    Worker classification rules determine if an individual is an employee or an independent contractor for purposes of unemployment insurance eligibility. The position will develop guidance for employers on factors that determine worker classification; will clarify the processes that employers or individuals should follow to submit additional information to this department in response to a legal determination and prior to an appeal; position will serve as a resource to the employer community on certain classification and audit matters. This position is a staff authority in worker classification.

    Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights MINIMUM QUALIFICATIONS: Education and Experience: Graduation from an accredited college or university with a bachelor's degree in Criminal Justice, Civil Justice, or Dispute Resolution AND three years of professional experience as a Hearings Officer who presided over appeals hearings for unemployment insurance claims.

    Substitutions: A combination of work experience in the occupational field or specialized subject area of the work assigned to the job, which provided the same kind, amount, and level of knowledge acquired in the required education, may be substituted on a year-for-year basis for the bachelor's degree. A JD or LLB degree may be substituted for the bachelor's degree and at the agency's discretion, for one or two years of required experience respectively. Required Competencies:

  • Expert in the Unemployment Insurance Appeals process.

  • Expert in worker classification. Preferred Skills/Experience: + Preferred candidate will have at least 5 years of experience holding Unemployment Insurance appeals hearings.

  • Experience explaining processes without providing legal advice.

  • Outstanding customer service skills for in-person and phone customers. Conditions of Employment: + As a condition of employment, you must successfully pass a background check (both criminal and unemployment insurance benefit overpayments). APPEAL RIGHTS:

    If you receive notice that you have been eliminated from consideration for the position, you may protest the action by filing an appeal with the State Personnel Board/State Personnel Director within 10 days from the date you receive notice of the elimination. Also, if you wish to challenge the selection and comparative analysis process, you may file an appeal with the State Personnel Board/State Personnel Director within 10 days from the receipt of notice or knowledge of the action you are challenging. Refer to Chapters 4 and 8 of the State Personnel Board Rules and Personnel Director's Administrative Procedures, 4 CCR 801, for more information about the appeals process.

    The State Personnel Board Rules and Personnel Director's Administrative Procedures are available at www.colorado.gov/spb. A standard appeal form is available at: www.colorado.gov/spb. If you appeal, your appeal must be submitted in writing on the official appeal form, signed by you or your representative, and received at the following address within 10 days of your receipt of notice or knowledge of the action:

    Colorado State Personnel Board/State Personnel Director, Attn: Appeals Processing, 1525 Sherman Street, 4th Floor, Denver, CO 80203. Fax: 303-866-5038.

    Phone: 303-866-3300. The ten-day deadline and these appeal procedures also apply to all charges of discrimination. Supplemental Information Minimum Qualification Screening A Human Resources Analyst will only review the work experience/job duties sections of the online job application to determine whether you meet the minimum qualifications for the position for which you are applying.

    Cover letters and resumes WILL NOT be accepted in lieu of the official State of Colorado online application, but may be attached. Part-time work experience will be prorated. Applicants must meet the minimum qualifications to continue in the selection process for this position.

    Work experience and qualifications must be specifically documented on your online application. Do not use "see resume" or "see attached" statements on your application. Resumes WILL NOT be reviewed for minimum qualification screening.

    Comparative Analysis Process – Structured Application Review After minimum qualification screening, the comparative analysis process for this position will involve a review and rating of all the information you submit with your application materials. Therefore, it is extremely important to document in the work experience/job duties portion of your online application the extent to which you possess the education, experience, minimum qualifications, and preferred qualifications as outlined in the job announcement. It is also important to thoroughly answer all supplemental questions as your answers to these questions will be evaluated during this phase.

    Any attachments such as cover letters, resumes or other documents that support your experience may also be reviewed during this phase. Supplemental Questions Answer the supplemental questions on the application completely and thoughtfully. Your answers may be rated based on your writing ability (spelling, grammar, and clarity of your writing) as well as the content of your answer.

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Appeals Specialist

McKesson is in the business of better health and we touch the lives of patients in virtually every aspect of healthcare. At McKesson Specialty Health, our products and services span the full continuum of specialty patient care.

From the initial phases of a product life cycle and the distribution of specialty drugs, to fully integrated healthcare technology systems, practice management support, and ultimately to patient care in the communities where they live, we empower the community patient care delivery system by helping community practices advance the science, technology and quality of care. We have a vision —that the long-term vibrancy of community care will be achieved through the leadership of physicians committed to clinical excellence and innovation, enabled by close collaboration with our organization and our deep clinical, operational and technological expertise.Every single McKesson employee contributes to our mission—by joining McKesson Specialty Health you act as a catalyst in a chain of events that helps millions of people all over the globe. You’ll collaborate on the products and solutions that help us carry out our mission to improve lives and advance healthcare.

Working here is your opportunity to shape an industry that’s vital to us all. Join our team of leaders to begin a rewarding career.

Position Description + Responsible for the enteringnew appeal cases and monitoring cases until appeal process is completed.

  • Completes preliminary investigation of the denied claims,checking for coding accuracy and gathering medicalrecords and supporting evidence from drug compendia.

  • Works on denials moderately complex in nature where judgmentis required to understand what medical recordsare required to support the necessity of treatment.

  • Normally receiveslittle or no instruction on routine work, general instruction and guidance on new or more complexcases.

Key Responsibilities + Organizes incomingappeal cases and maintains timelyfollow-up actions for the case + Preliminary investigation to determine the reason for the denial through researchof the FDA drug label,Compendia, and medicallibrary resources.

  • Gathers necessary medical records to support the appeal on denied dates of service.

  • Audit denied claim(s)for accuracy of coding. Requiresknowledge of ICD-10 CPT and HCPCS code sets.

  • Ability to developand write an appeal argumentwith the supportof the Clinical AppealsSpecialist.

  • Maintains knowledgeof pharmaceutical patientassistance programs to seek appropriate support on lost cases.

Minimum Requirements 3 years of medical billing experience with account follow-up and/or appeals

Critical Skills + Knowledge of medical terminology + Knowledge of medical billingprocesses + Knowledge of medical coding (ICD-10, CPT and HCPCS code sets) + Knowledge of Microsoft Word and Excel + Strong writtenand oral communication skills + Critical thinking skills Additional Knowledge & Skills

Additional medical billing or coding education preferred Education High School Diploma or equivalent work experience; CCP or AAPC preferred.

Physical Requirements

General Office Demands Benefits & Company Statement McKesson believes superior performance – individual and team – that helps us drive innovations and solutions to promote better health should be recognized and rewarded. We provide a competitive compensation program to attract, retain and motivate a high-performance workforce, and it’s flexible enough to meet the different needs of our diverse employee population.

We are in the business of better health and we touch the lives of patients in virtually every aspect of healthcare.

We partner with payers, hospitals, physician offices, pharmacies, pharmaceutical companies and others across the spectrum of care to build healthier organizations that deliver better care to patients in every setting. But we can’t do it without you.

Every single McKesson employee contributes to our mission—whatever your title, whatever your role, you act as a catalyst in a chain of events that helps millions of people all over the globe. Talented, compassionate people are the future of our company—and of healthcare. At McKesson, you’ll collaborate on the products and solutions that help us carry out our mission to improve lives and advance healthcare.

Working here is your opportunity to shape an industry that’s vital to us all. McKesson is an equal opportunity and affirmative action employer – minorities/females/veterans/persons with disabilities. Qualified applicants will not be disqualified from consideration for employment based upon criminal history.

Agency Statement No agencies please.

Job:Medical

Organization:McKesson Specialty Health

Title:Appeals Specialist

Location:Kansas-Overland Park

Requisition ID:17003983



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Appeals Management Analyst

Appeals Management Analyst + Analyze new denials including + Review third party correspondence + Reassign cases that don’t require clinical intervention to Patient Accounting + Refer potential IP-AMS re-bills to the Assistant Director, Clinical Data Management (ie registration errors) + Obtain formal denial letters if possible + Verify Appeal addresses + Assign risk amount + Maintains documentation on denied cases in EPIC based on findings obtained during telephonic discussion with third party payers + Identify denial trends and report them to the Assistant Director, Clinical Data Management for follow-up + Request medical records and follow-up on outstanding requests + Maintain appeals correspondence file + Prepare cases for Appeals Manager upon receipt of medical record + Assist Appeals Manager with mailings + Communicate findings with Patient Accounting and Finance + Refer closed cases to the Assistant Director, Clinical Data Management for further analysis + Provide assistance in the day to day administrative duties for the appeals management program Requirements + Associates Degree required - Bachelors Degree highly desirable + Minimum 2 to 3 years experience with hospital revenue cycle; Inpatient and Outpatient Billing; experience with denials/appeals management highly desirable + Proficient with Microsoft; Eagle; Epic; Allscripts Care Management; Database management + Good customer service skills; attention to detail; flexible; ability to multi-task; Critical thinking ability #LI-JL1 ID: 2017-8739 Hours per Week: 35 Shift: Days External Company Name: Hospital for Special Surgery External Company URL: www.hss.edu


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Clinical Appeals Analyst

Job Description: Responsible for the analysis, research and completion of complex, non-routine appeals and grievances within the company. Will address all customer concerns and ensure resolution and satisfaction. Ensure timeliness, quality and efficiency in all work to comply with mandated, legislative, North Carolina Department of Insurance (NCDOI) and National Committee for Quality Assurance (NCQA) and Federal requirements. Note: This job reports to Manager, Nursing or Team Leader, Medical only.

  • Provide clinical consultation with non-clinical staff within the Appeals Department.

  • Coordinate all aspects of the appeals process to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI, legislative, federal and NCQA requirements, as applicable.

  • Assist with Level 3 appeals as required.

  • Analyze complex/non-routine member and provider appeals and grievances for all lines of business, excluding FEP, by reviewing CMP, contract provisions, legislation and/or NCQA requirements.

  • Identify appropriate documentation collection from multiple external sources such as pharmaceutical companies, attorneys, providers, etc.

  • Present analysis and documentation to appropriate physician committee, benefit administrators and BCBSNC leadership, as necessary.

  • Initiate claim adjustments on individual cases when necessary.

  • Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by mandates and legislation.

  • Identify trends and high-risk issues to make recommendations to address future exposure.

  • Identify and take corrective action on appeals that result from noncompliance of contract provisions, appeal guidelines and/or CMP.

  • Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors.

  • Answer member/provider questions via incoming telephone calls in a professional quality driven manner.

  • May handle complaints/grievances as defined by the federal government.

  • Coordinates with external vendors and provides requested information as requested. Hiring Requirements + Registered Nurse in the state of North Carolina + 3 years of clinical experence; OR + Licensed Practical Nurse, Physical Therapist, Occupational Therapist, Licensed in the State of North Carolina and 5 years of clinical experience. Hiring Preferences + Managed care experience

  • Experience with Blue Cross and Blue Shield of North Carolina products and systems.

  • System knowledge should include understanding and usability of MaxMC, Power MHS, Service First, Magic, Mobius, Doc Request, Medco and accessing Corporate Medical Policy.

  • Experience with of MS Word, Access, and Excel.

  • Ability to research and problem solve + Able to read and understand claims history, denials, payments, suspends + Strong Medical Knowledge

  • Ability to make concise, independent and defensible decisions in often high-pressure situations + Effective verbal and written communication and presentation skills + Excellent analytical, planning and problem-solving skills

  • Ability to successfully interface with individuals at all levels, including top management, both internal and external + Excellent time management skills

  • Ability to be discreet and diplomatic

  • Ability to work independently, as well as with a team + Certified Professional Coder preferred. It's an exciting time to work at Blue Cross and Blue Shield of North Carolina. Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Our company is a not-for-profit with headquarters in Durham and major operations in Winston-Salem and Fayetteville. In all we employ more than 4,500 North Carolinians and serve more than 3.7 million customers. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

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Appeals Management Analyst

Overview: Appeals Management Analyst + Analyze new denials including + Review third party correspondence + Reassign cases that don’t require clinical intervention to Patient Accounting + Refer potential IP-AMS re-bills to the Assistant Director, Clinical Data Management (ie registration errors) + Obtain formal denial letters if possible + Verify Appeal addresses + Assign risk amount + Maintains documentation on denied cases in EPIC based on findings obtained during telephonic discussion with third party payers + Identify denial trends and report them to the Assistant Director, Clinical Data Management for follow-up + Request medical records and follow-up on outstanding requests + Maintain appeals correspondence file + Prepare cases for Appeals Manager upon receipt of medical record + Assist Appeals Manager with mailings + Communicate findings with Patient Accounting and Finance + Refer closed cases to the Assistant Director, Clinical Data Management for further analysis + Provide assistance in the day to day administrative duties for the appeals management program Requirements + Associates Degree required

  • Bachelors Degree highly desirable + Minimum 2 to 3 years experience with hospital revenue cycle; Inpatient and Outpatient Billing; experience with denials/appeals management highly desirable + Proficient with Microsoft; Eagle; Epic; Allscripts Care Management; Database management + Good customer service skills; attention to detail; flexible; ability to multi-task; Critical thinking ability Other Requirements: #LI-JL1 Job ID 2017-8739 Location US-NY-New York Posted Date 5/31/2017 Category Administrative/Clerical Support

  • All Openings Emp Status Regular Full-Time Hours per Week 35 Shift Days

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Clinical Appeals Analyst

JOB DESCRIPTION:

Responsible for the analysis, research and completion of complex, non-routine appeals and grievances within the company. Will address all customer concerns and ensure resolution and satisfaction. Ensure timeliness, quality and efficiency in all work to comply with mandated, legislative, North Carolina Department of Insurance (NCDOI) and National Committee for Quality Assurance (NCQA) and Federal requirements. Note: This job reports to Manager, Nursing or Team Leader, Medical only.

    • Provide clinical consultation with non-clinical staff within the Appeals Department.
    • Coordinate all aspects of the appeals process to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI, legislative, federal and NCQA requirements, as applicable.
    • Assist with Level 3 appeals as required.
    • Analyze complex/non-routine member and provider appeals and grievances for all lines of business, excluding FEP, by reviewing CMP, contract provisions, legislation and/or NCQA requirements.
    • Identify appropriate documentation collection from multiple external sources such as pharmaceutical companies, attorneys, providers, etc.
    • Present analysis and documentation to appropriate physician committee, benefit administrators and BCBSNC leadership, as necessary.
    • Initiate claim adjustments on individual cases when necessary.
    • Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by mandates and legislation.
    • Identify trends and high-risk issues to make recommendations to address future exposure.
    • Identify and take corrective action on appeals that result from noncompliance of contract provisions, appeal guidelines and/or CMP.
    • Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors.
    • Answer member/provider questions via incoming telephone calls in a professional quality driven manner.
    • May handle complaints/grievances as defined by the federal government.
    • Coordinates with external vendors and provides requested information as requested.

HIRING REQUIREMENTS

  • Registered Nurse in the state of North Carolina

    • 3 years of clinical experence; OR
  • Licensed Practical Nurse, Physical Therapist, Occupational Therapist, Licensed in the State of North Carolina and 5 years of clinical experience.

HIRING PREFERENCES

  • Managed care experience

  • Experience with Blue Cross and Blue Shield of North Carolina products and systems.

    • System knowledge should include understanding and usability of MaxMC, Power MHS, Service First, Magic, Mobius, Doc Request, Medco and accessing Corporate Medical Policy.
    • Experience with of MS Word, Access, and Excel.
    • Ability to research and problem solve
  • Able to read and understand claims history, denials, payments, suspends

  • Strong Medical Knowledge

  • Ability to make concise, independent and defensible decisions in often high-pressure situations

  • Effective verbal and written communication and presentation skills

  • Excellent analytical, planning and problem-solving skills

  • Ability to successfully interface with individuals at all levels, including top management, both internal and external

  • Excellent time management skills

  • Ability to be discreet and diplomatic

  • Ability to work independently, as well as with a team

  • Certified Professional Coder preferred..

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