Clinical Appeals & Denials Specialist

Riverside Healthcare; Kankakee (IL); On-site; USD 43,000 - 56,000; Full time

Benefits offered by this job

Health benefits

Retirement plan

Educational assistance

Job summary

The Clinical Appeals Analyst at Riverside Healthcare is responsible for managing and processing clinical appeals and denials for various payers. This role requires a deep understanding of clinical documentation, medical necessity criteria, and payer policies to develop and submit compelling appeal cases.

The Clinical Appeals Analyst works closely with medical providers, revenue cycle teams, and insurance representatives to ensure the appropriate reimbursement for healthcare services.

Qualifications

• Bachelor's degree in Nursing, Healthcare Administration or related field.
• 3+ years of clinical appeals or revenue cycle experience.
• Strong knowledge of payer policies and medical necessity criteria.
• Excellent analytical and communication skills.

Responsibilities

• Review denied claims and determine basis for appeal.
• Draft and submit clinical appeals with supporting records.
• Collaborate with providers, coding, CDI and revenue cycle teams.
• Conduct root cause analysis to identify denial trends.
• Monitor appeal status and follow up with payers.
• Maintain log of appeals and outcomes.
• Stay updated on payer policies and regulatory changes.
• Develop reports on appeals activity for leadership.
• Analyze refund requests for inpatient accounts.

Skills

Clinical appeals

Utilization management

Revenue cycle

Payer policies

Medical necessity

Analytical skills

Communication skills

Epic

Education

Nursing/Healthcare Admin

Tools

Epic

Job description

The Clinical Appeals Analyst at Riverside Healthcare is responsible for managing and processing clinical appeals and denials for various payers. This role requires a deep understanding of clinical documentation, medical necessity criteria, and payer policies to develop and submit compelling appeal cases.

The Clinical Appeals Analyst works closely with medical providers, revenue cycle teams, and insurance representatives to ensure the appropriate reimbursement for healthcare services.