行业：Healthcare
职位：Practitioner / Medical Asst
部门：
人数：若干
性质：Full Time
性别：Male
婚姻：No marital status restrictions
学历：Open to all levels
经验：不限
年龄：18岁以上
待遇：面议
COMPANY BENEFITS:HMO with FREE 3 DependentsGroup Life Insurance coveragePaid Time-off credits of up to 20 days in a year10% Annual Performance based incentive
Location: Taguig, BGC
Shift: Morning Shift Schedule (6 AM - 3PM)
Work Arrangement: Onsite
Job DescriptionThe Clinical Appeals Reviewer/Clinical Denials Clinician for the Appellate Solution is responsible for:
a) Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
b) Preparing and documenting appeal based on industry accepted criteria.
Responsibilities and Duties
- Performs retrospective (post-discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
- Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
- Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process.
- Demonstrates proficiency in use of medical necessity criteria sets,MCG and InterQual®, as evidenced by Inter-rater reliability studies and other QA audits.
- Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs) Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office.
- Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.