Clinical Appeals Coordinator - Pre Authorization

Responsibilities

• Reviews patient medical records and collects data for billing and/or appeals process management, analysis, studies, and monitoring. Communicates with insurer to determine if payments/denials are appropriate.
• Collect, review and perform timely appeals on medical necessity denials and/or authorization denials.
• Participates in planning system-wide measurement initiatives with respect to assessment and management of accounts to determine patterns and trends of payment and/or denials and facilitates communication to improve performance and educate management.
• Maintains an understanding of current TJC standards pertaining to denial and appeals management; assists the university hospitals and health system to maintain compliance with regulatory standards, federal and local as it pertains to denial of claims.
• Provides timely internal/external customer service in a cooperative, professional, and respectful manner.
• The duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time.
• Physical and Environmental Demands
• Requires occasional exposure to unpleasant or disagreeable physical environment

Benefits

Additional Information

Hello, Thank you for your interest in career opportunities with the University of Mississippi Medical Center. Please review the following instructions prior to submitting your job application: Provide all of your employment history, education, and licenses/certifications/registrations. You will be unable to modify your application after you have submitted it. You must meet all of the job requirements at the time of submitting the application. You can only apply one time to a job requisition. Once you start the application process you cannot save your work. Please ensure you have all required attachment(s) available to complete your application before you begin the process. Applications must be submitted prior to the close of the recruitment. Once recruitment has closed, applications will no longer be accepted. After you apply, we will review your qualifications and contact you if your application is among the most highly qualified. Due to the large volume of applications, we are unable to individually respond to all applicants. You may check the status of your application via your Candidate Profile. Thank you, Human Resources Important Applications Instructions: Please complete this application in entirety by providing all of your work experience, education and certifications/ license. You will be unable to edit/add/change your application once it is submitted. Job Requisition ID: R00045678 Job Category: Nursing Organization: Rev Cycle - Patient Access PAU Location/s: Main Campus Jackson Job Title: Clinical Appeals Coordinator - Pre Authorization Job Summary: To provide coordination and support of university hospitals and health system /university physician billing process and the denials and appeals review process. To participate in the review, evaluation, monitoring, measuring and adjustment of all patient care payments denials and associated claims; participates in the development of risk minimization appeals program. Conducts research including departmental interviews/communication for verification of denial, clinical review of the denial, and conducts a reporting process for quality improvement initiatives to prevent future issues. Education & Experience Associates degree in nursing (ADN) plus five (5) years of clinical nursing experience or a Bachelors in a nursing plus three (3) years of clinical nursing experience. Utilization review and/or case management is preferred. Certifications, Licenses or Registration Required: Valid RN license. Knowledge, Skills & Abilities Knowledge and understanding of clinical organization structure, workflow, and operating procedures. Skill in the use of personal computers and related software applications. Ability to manage multiple priorities under time constraints; ability to analyze and solve problems. Understanding cost and quality issues. Verbal and written communication skills. Interpersonal skills to interact with a wide range of constituencies. Decision-making skills.

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