Clinical Appeals Analyst (Remote) - FT

The Clinical Appeals Specialist is responsible for assisting the Corporate Director of Appeals Management (hereafter known as “Director”) by conducting a comprehensive analytic review of clinical documentation and complete the appeal process. The Clinical Appeals Specialist will write sound, compelling letters to support the appeal. They may also attend Administrative Law Judge hearings, handle audit related correspondence and other administrative duties as required. This is an exempt position.

I. Job Responsibilities:

· Review patient medical records and utilize clinical and regulatory knowledge and skills, as well as, knowledge of payer requirements to determine why cases/claims are denied and complete an appeal.

· Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments.

· Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory guidelines to prepare the response to the payer in an effort to overturn the denial in a professional and concise manner.

· Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory guidelines to prepare for an Administrative Law Judge hearing and participate in hearings by providing testimony, as necessary.

· Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Actively seek out opportunities for appeal by reviewing all insurance denials within assigned region.

· Prepare data and analytics and share with the Director and Executive Team and provide feedback to hospitals regarding trends in denied claims.

· Discuss documentation-related and level of care decisions with hospitals, independently, as required.

· Have the ability to proficiently read, understand and communicate in writing abstract information from patient medical records in a professional manner. Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information

· Ensure compliance with HIPAA regulations, including confidentiality, as required.

· Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information.

· Other duties as assigned.

· Audit selected medical records to determine compliance with CMS guidelines and regulations. Coordinate with hospitals to correct any deficiencies prior to submission of records to auditors. Coordinate with government auditors to provide additional information as needed and set up educational sessions with hospitals following completion of audits. Maintain all required documentation related to assigned audits.

II. Leadership

· Inclusiveness: Promotes cooperation, fairness and equity; shows respect for people and their differences; works to understand perspectives of others; demonstrates empathy; brings out the best in others and in his/her team.

· Stewardship and Resource Management: Demonstrates accountability and sound judgment in managing company resources. Appropriate understanding of confidentiality and company values. Adheres to and supports company policies, procedures and safety guidelines.

· Problem-Solving: Identifies problems, involves others in seeking solutions. Conducts appropriate analysis. Searches for best solutions. Effectively and efficiently implements appropriate response to correct problems. Responds promptly and effectively to new challenges.

· Decision-Making: Makes clear, consistent decisions. Acts with integrity in all decisions. Distinguishes relevant from irrelevant information. Makes timely, appropriate decisions.

· Communication: Connects with peers, subordinate employees and all customers. Actively listens. Clearly and effectively shares information. Demonstrates effective oral and written communication skills. Negotiates effectively.

· Quality Improvement: Strives for efficient, effective, high-quality performance in self and the department. Delivers timely and accurate results. Resilient when responding to matters that are challenging. Takes initiative to make improvements.

· Teamwork: Encourages cooperation and collaboration. Builds effective teams. Works in partnership with others. Is flexible. Responsive to the needs of others.

· Development: Maintains up-to-date skills through involvement with professional organizations or continuing education.

III. Customer Service

· Maintains the highest level of customer service via courtesy, compassion and positive communication.

· Promotes the Mission and Vision of Post Acute Medical within the work environment and the community.

· Respects dignity and confidentiality by adherence to all applicable policies and procedures.

IV. Health and Safety

· Works in a manner that promotes safety; wears clothing appropriate to the performance of the job.

· Participates in OSHA required training

· Follows universal precautions as appropriate for position; complies with Employee Health requirements for continued employment

· Reports unsafe practices to management.

· Knows own role in case of an emergency

Education and Training: Five years’ experience as a clinical nurse in an acute care setting. Current state-issued RN license. 

Experience: Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting. In addition, having at least two to three years of experience in case management, discharge planning, and/or utilization review is preferred.

Knowledge, Skills, and Abilities: Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by auditors. Knowledge in areas such as InterQual Level of Care and Milliman & Robertson criteria. Knowledge of third party payer regulations related to utilization and quality review is preferred. Knowledge of MAC, RAC, ZPIC denials and process. Ability to travel as required.

ABOUT US

PAM HEALTH (PAM) based in Enola, Pennsylvania, provides specialty healthcare services through more than 70 long-term acute care hospitals and physical medicine and rehabilitation hospitals, as well as wound clinics and outpatient physical therapy locations, in 17 states. PAM Health is committed to providing high-quality patient care and outstanding customer service, coupled with the loyalty and dedication of highly trained staff, to be the most trusted source for post-acute services in every community it serves. Its mission is to serve people by providing compassionate, expert care, and to support recovery through education and research.

Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay, generous paid benefit time, and excellent insurance options, you will also have opportunities for professional growth through our Education Advancement Program.

We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program. Please take a moment to visit us online at www.PAMHealth.com for a comprehensive look at how we're able to positively impact our local communities.

PAM Health does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.