- Optum (San Juan, PR)
- …and obtain additional information needed to make an appropriate determination Determine if appeal review is clinical or administrative Research and make ... cases Coordinate with business partners to obtain decisions when appropriate Review member benefit information, provider specific information/contracts, claims ,… more
- Vidant Health (Greenville, NC)
- …coding software tools and Insurance carrier medical and reimbursement policies during the claim review process. Responsibilities Review and analyze coding, ... denials. Integrates the payer medical policies, case specific medical documentation, and claims information into a concise appeal letter, including appropriate… more
- Hoag Memorial - Red Hill Clinic (Costa Mesa, CA)
- …Client Name Hoag Memorial - Red Hill Clinic Job Type Local Offering Non- Clinical Profession Medical Biller Specialty Hospital Job ID 16776482 Job Title Collector I ... queues. *Obtains the maximum amount of reimbursement by evaluating claims at the contract rate with the use of...(Examples: APC, DRG, APRDRG). *Reviews and initiates the initial appeal for underpayments, observing all timely requirements to secure… 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
- Molina Healthcare (Houston, TX)
- …of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and...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
- Houston Methodist (The Woodlands, TX)
- …revenue cycle regarding any claim issues or concerns that may require clinical review during the pre-bill, audit, or appeal process. **GROWTH/INNOVATION ... cases to the Physician Advisor (or services) for appropriate second level review , peer-peer discussions, and payer denial- appeal needs. Consults with… more
- Guidehouse (Huntsville, AL)
- …Will Do** **:** The **R** **emote** ** Clinical Denials RN** is responsible for review , analysis and appeal of clinical denials from insurance companies ... Mid-Revenue Cycle + Research and application of regulatory policies to support clinical appeal + Telephonic communication with payors, provider, hospital staff… more
- Cedars-Sinai (Beverly Hills, CA)
- …are not limited to payor update reviews, claim data analysis, assist with appeal process, review and incorporate payor clinical criteria into medication ... nine years in a row on the "Best Hospitals" Honor Roll. The Clinical Prior Authorization Pharmacist Specialist at Cedars-Sinai Medical Center will work in… more
