Job Attributes

Work Schedule/Shift

Day

Job ID

5000430842406

Req. No

70032632

Job Title

Clinical Appeals Specialist

Region

CHRISTUS System Office

Category

Healthcare

Division

Not Defined

Company

CHRISTUS Health

Travel

None

Facility

CHRISTUS Health-68600

Address

919 Hidden Ridge
Irving, TX  75038
US

Type

Full Time

Apply Now Clinical Appeals Specialist Job in Irving

The Clinical Appeals Specialist serves to organize, negotiate, and communicate clinical claim denials with internal clinical staff and the financial services department, as well as external claims representatives of a variety of insurers. In order to optimize the recovery of reimbursement from denied claims and, thereby, enhance the overall financial outcome for CHRISTUS Health, this position manages the claims denial database and provides technical support activities for clinical appeals/audits, including timely medical record releases. This requires timely, articulate direct communication to all stakeholders, with appropriate supporting clinical documentation for unique payer utilization and claims submission requirements. The incumbent supports this activity with the CHRISTUS Health facilities and the Clinical Appeals Nurses. This position further enables financial recovery reporting for CHRISTUS Health leaders and support for contract negotiation with payers, especially managed care companies.


MAJOR RESPONSIBILITIES

Properly identify denial type and category to ensure appropriate management of audits and denials.
Obtains necessary information needed to complete an audit/appeal; ensures timely responses and updates in all required systems.
Assures the denials database is accurate and remains up-to-date; organize and prioritize data input into this system.
Work in conjunction with Patient Financial Services (PFS) to reconcile denial payments and recoupments in the denial database.
Coordinates timely medical record and claims reviews with the facilities.
Collaborate closely with the payers, vendors, Appeals Nurses, Coding Integrity Team, and regional Audit Coordinators to assure they are informed regarding appeal decisions, denials and recoupments.
Provides feedback to members of the healthcare team (health information management (HIM), case management, PFS, etc.) regarding charging, documentation, patient status and coding issues so changes can be made to prevent future revenue risk.
Works with corporate department and leaders, communicating information regarding payer activities and outcomes as needed on specific cases.
Monitors and assures compliancewith all policies, procedures and standards as promulgated by state and federal agencies, the facilities, and other regulatory entities.
Monitors and assures accuracy of all information in communications and data base administration.

A. Education/Skills

High school diploma required; post high school education preferred.
Ability to communicate with multiple levels in the organization (e.g. managers, clinical, and support staff).
Excellent organizational skills including effective time management, priority setting and process improvement.

B. Experience

Minimum of two years' experience of coding and billing/collection operations.
Understands the difference in billing, collections, payments, and refunds for governmental, managed care, and commercial payers.
Possess an understanding of accounts receivables and claim denials.
Knowledgeable and/or previous experience in Medicare Recovery Audits and managed care audit processes
Must demonstrate competence in project management and completing data entry, data analysis, and data interpretation.
Computer experience in Microsoft Office (Word and Excel).

C. Licenses, Registrations, or Certifications

None

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