- EmblemHealth (New York, NY)
- …Collaborate with Dental Consultants to review and triage escalated claims , pre-determinations, and service requests. Integrate clinical expertise with ... analyze, and investigate member benefits, policy and procedures for claims , grievance and appeal cases. Provide provider...the supporting documentation submitted with claim . Refer clinical denials to consultant for review with… more
- Kaiser Permanente (Denver, CO)
- …If the claim was denied correctly, forwards to appropriate staff for appeal review or enters authorization to pay correctly if appropriate. Build spreadsheet ... limited to: Macess, SharePoint, Health Connect, DOI issues, emails, review benefit exceptions, visiting member claims , self-funded...be made send info to Harrington Health requesting additional claim information. Daily review of the retro… more
- CERiS (Fort Worth, TX)
- … to audit finding generation and appeal management. Oversee the entire clinical claims review process, understanding various client configurations and ... for the development, implementation, and oversight of all DRG clinical validation and audit initiatives. This role ensures the...claim selection and clinical review… more
- University of Iowa Hospitals & Clinics (Iowa City, IA)
- …for payment acquisition, pre-authorization and to resolve patient account inquiries. Appeal /troubleshoot claim payments and/or denials using available resources. ... information. Initiate and follow through for required prior authorizations. Assist clinical pharmacy specialists or other providers with initiation of appeals when… more
- UPMC (Pittsburgh, PA)
- …established processes. + Collaborate with physician leadership as warranted in preparation of appeal / clinical review responses. + BSN or Bachelors degree ... your career? UPMC is hiring a full-time Revenue Cycle Clinical Review Nurse. This position works Monday...the local care management departments by initiating the retrospective appeal process for acute inpatient clinical denials… more
- Corewell Health (Grand Rapids, MI)
- …+ Resolve appeal requests prior to committee or fair hearing review , when appropriate, including collaboration internally with all levels within the organization ... knowledge of policies and procedures, including medical policies which may impact the appeal and review process Preferred + Intermediate or advanced level using… more
- CVS Health (Hartford, CT)
- …of this Medical Director role include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered ... Medical Director role include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …the most appropriate decision within regulatory timeframes.The TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will ... The RoleThe Clinical Appeals Nurse Reviewer is responsible for applying sound clinical judgement to review provider and member appeals for denied services… more
- HCA Healthcare (Dallas, TX)
- …each individual is recognized. Submit your application for the opportunity below: Clinical Denials Coding Review SpecialistParallon. **Benefits** Parallon, offers ... benefits may vary by location._** We are seeking a Clinical Denials Coding Review Specialist for our...as it relates to researching, analyzing, and resolving outstanding clinical denials and insurance claims . This job… more
- St. Luke's University Health Network (Allentown, PA)
- …regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- Baptist Memorial (Memphis, TN)
- …performing activities related to denied claims such as obtaining authorizations, claims review , patient billing, appeal writing, auditing, and/or denial ... appeal , collaborate with coding/billing for formulation of appeal with corrected claims and denial resolution...Physician Advisor communication may be necessary to provide further clinical review from the physician perspective as… more
- Beth Israel Lahey Health (Plymouth, MA)
- …contract changes as they pertain to level of care determination and the appeal /denial process. + Oversees utilization review workflow processes to ensure timely ... for identified deficiencies. + Facilitates peer-to-peer communication in support of submitted claims . + Participates on the Utilization Review Committee +… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …medical information was provided to the third-party payer. + If necessary, helps clinical team understand denial and coordinates appeal process. + Creates cost ... clinical and/or related experience required. Case Management, Utilization Review and/or Prior Authorization experience is preferred. + **Certification/Licensure/Registration:**… more
- JB Hunt Transport (Lowell, AR)
- …keeping with applicable benefit plan guidelines, and present claim appeals to the Appeal Review Board, providing clinical insight specific to each case + ... with insured member, plan administrators, and provide support for clinical transitions, as necessary, as it relates to benefit...claim cases. + Assist with claim appeal process; gather information and prepare for review… more
- Intermountain Health (West Valley City, UT)
- …governmental insurance appeals using supporting documentation. 2. Assesses the appropriateness of clinical appeal requests by using payer policies and Federal ... **Job Description:** Uses nationally recognized, evidence-based utilization criteria to review medical records and perform clinical assessments for patient… more
- Molina Healthcare (Midvale, UT)
- …of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of ... with internet connectivity of high speed required._ **Job Summary** Clinical Appeals is responsible for making appropriate and correct...specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long… more
- Houston Methodist (Houston, TX)
- …with physicians, revenue cycle personnel, and payers to successfully clear front end claim edits, appeal clinical denials, and address customer service ... + Integrates the payer medical policies, case specific medical documentation, and claims information into a concise appeal letter, including appropriate medical… more
- City and County of San Francisco (San Francisco, CA)
- …2574 positions + All City departments with open permanent positions can review your application Under general supervision, conducts professional-level work in ... clinical psychology; carries out psychodiagnostic examinations and psychotherapy of...on the application form the language(s) in which they claim proficiency. Important Note: Please make sure it is… more
- University of Rochester (Rochester, NY)
- …in claim resolution process for Strong Memorial Hospital (SMH) clinical staff and outside agencies regarding contractual obligations. Assures on-going positive ... **Responsibilities:** GENERAL PURPOSE With considerable latitude for independent judgment, the Claim Resolution Rep IV is responsible for the follow up and… more
- Great River Health (West Burlington, IA)
- …an ongoing basis regarding clinical documentation.What you will do + Clinical documentation review of documentation-Accurate and timely record review ... information. + Excellent organization skills-Manage multiple priorities-Regular and reliable attendance. + Appeal denied claims and follow up on the appeal… more
