Coordinator-Clinical Appeals

Job Summary: The Coordinator-Clinical Appeals is responsible for the support of the daily function and operations of the Billing and Collections department by reviewing and appealing clinical denials as well as retro authorizations. Interfaces with payors, Case Managers, Insurance Verification department, Financial Counselors, PBO, and Health Information Management department. Reviews medical records for medical necessity of admission, severity of illness, and intensity of service based on InterQual and Milliman Guidelines. Documents in appropriate systems the results of retro authorization and denial or appeal efforts. Reviews referred accounts for appropriate trauma charges, as well as NICU when requested, when charges are inconsistent. Composes and sends appeal letters to payor when denial is in violation of state and federal laws as well as due to lack of sufficient information sent to payor. Evaluates and reviews in-patient hospitalizations for delay of service and delay of discharge. Reviews all findings and appeal letters with Denial Clinical Appeals Unit (CAU) Management. Participates in department quality improvement projects. These services may be provided for all LLUH facilities. Performs other duties as needed.

Education and Experience: Minimum three years of experience in utilization management, utilization review or managed care within a hospital or related healthcare facility required.

Knowledge and Skills: Knowledge of health plan and medical group contracts including Medi-Cal and Medicare. Knowledge of InterQual and Milliman criteria for in-patient hospitalization. Able to read; write legibly; speak in English with professional quality; use computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint). Operate and troubleshoot basic office equipment required for the position. Able to relate and communicate positively, effectively, and professionally with others; work calmly and respond courteously when under pressure; collaborate and accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; manage multiple assignments effectively; organize and prioritize workload; work well under pressure; problem solve; recall information with accuracy; pay close attention to detail; work independently with minimal supervision. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position.

Licensures and Certifications: Basic Life Support (BLS) certification issued by the American Heart Association required. Nationally recognized certification in Utilization Management, Utilization Review, Hospital Utilization, Managed Care or Health Care related area preferred. California Vocational Nurse (LVN) license preferred. Medical Terminology certification accepted in lieu of LVN license.