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RN Clinical Appeal and Audit Coordinator

Position Summary: The Appeal & Audit Coordinator will appeal all inpatient level of care denials through medical record review meeting the Medicare, Medicaid and private insurer contractual deadlines for denial reconsideration. The Appeal & Audit Coordinator will coordinate and appeal all external payer audits by performing chart review analysis and data collection for recovery strategies and payment accuracy. The Appeal and Audit coordinator is responsible to assist with outpatient appeals on an as needed basis. Responsibilities: 1. Upon receipt of verbal and/or written denial notification for inpatient level of care denials, outpatient denials or audit findings, the appeal process will be implemented by analyzing and reviewing the medical record documentation  2. Generates an appeal letter to substantiate the medical necessity findings for the inpatient admission utilizing the Interqual Criteria  3. Generates an appeal letter providing the supporting clinical documentation for the inpatient level of care denial, the outpatient level of care denial and audit denial findings  4. Is able to differentiate the difference between observation level of care and inpatient level of care admissions  5. Collaborates with HIM to obtain copy of patient's medical record as needed  6. Consults with case management and/or the attending physician regarding the case in review as needed 7. Submits an appeal packet to the denying insurer within the contractual appeal timeframes including all required supporting documentation  8. Submits a second level of appeal when applicable 9. Coordinates with the attending physician to obtain his/her letter of appeal for all MassPRO and other insurers if applicable 10. Develops, maintains, and manages cases utilizing an internal tracking system as appropriate (i.e. denial/appeal summary, outpatient denial summary and audit summary) 11. Identifies and monitors payer and/or operational issues on the monthly denial/appeal summary, outpatient denial summary and/or audit summary 12. Documents in BAR, Allscripts and all supporting internal applications  13. Review account information in billing system (BAR) with the central billing office to verify payments are correct and take action as necessary 14. Participates in on-site audit process (including exit interview) 15. Review records as needed per internal guidelines prior to submission to payer for off-site audit 16. Communicates with the external auditor for clarification of audit findings as needed 17. Review insurer contracts giving input into potential issues that would pertain to inpatient denials, outpatient denials and audit findings 18. Consult with other disciplines and other ancillary departments (i.e. physician, coding, OR, cardiology, pharmacy, purchasing, case management, respiratory therapy, clinical documentation specialists, etc.) as needed to obtain necessary documentation to support clinical appeal 19. Coordinate submission of hospital's audit appeal response with other disciplines (i.e. patient accounts), as needed, within time limits identified by the audit report 20. Identify trends as a result of external audit findings and monitor audit activity on audit tracking tool 21. Working knowledge of the inpatient denial process, the outpatient denial process and audit process 22. Perform other duties as required Qualifications: Minimum Education:  1. Bachelor of Science Degree or a licensed registered nurse with equivalent relevant experience 2. Current licensure in Massachusetts as a Registered Nurse Minimum Experience: 1. Five years experience in acute care setting  2. Three to five years experience in managed care environment/benefits management 3. Three to five years experience in Quality, Utilization Review, and/or Case Management 4. Knowledge of insurance state and federal regulations 5. Knowledge of the claims audit process 6. Outstanding leadership and interpersonal skills 7. Excellent written skills 8. Effective verbal communication 9. Computer knowledge including data entry, and use of an excel spread sheet 51141
Salary Range: NA
Minimum Qualification
5 - 7 years

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