Clinical Appeals Writer
CA Registered Nurse
The Clinical Appeals Writer's role consists of reviewing and appealing for reconsideration medical services that may have been denied or underpaid, either in part or in whole, during the initial claims determination phase.
Reviews cases to determine the potential for a provider appeal on denied or underpaid claims. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not Medically Necessary. The clinical review of the denied stays will be evaluated in terms of type, frequency, extent, site and duration of patient's illness and/or injury or disease.
Writes requests for reconsideration in an objective narrative form, utilizing appropriate formatting, English grammar, current nationally accepted criteria, medical literature, if applicable, healthcare statutes and prudent clinical judgment. Letters will include appropriate review of the clinical facts and the medically appropriate reasons for reconsideration of the denial or underpayment. California Registered Nursing License is required. 5 years of experience in nursing and utilization review, with 2 of those years successfully appealing managed care denials and underpayment decisions.
Possess knowledge and experience with national clinical criteria applied in Case Management including InterQual and Milliman standards. Working knowledge of billing codes, Revenue Codes, CPT's, etc. Experience and knowledge of managed care contracts, account receivables and revenue cycle functions.