Coordinator-Clinical Appeals

Job Description Job Summary The Coordinator-Clinical Appeals is responsible for supporting 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 the results of retro authorization and denial or appeal efforts in appropriate systems. 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. Relate and communicate positively, effectively, and professionally with others; work calmly and respond courteously when under pressure; collaborate and accept direction. 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. Distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone; 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. Equal Opportunity Employer Loma Linda University Health is a Seventh-day Adventist, faith-based Christian institution. Candidates must understand and embrace the mission, purpose, and identity of Loma Linda and its affiliated entities. We are an equal opportunity employer committed to the principles of diversity. We provide equal opportunities in all aspects of the employment process to every individual, regardless of gender, race, color, age, national origin, ancestry, physical or mental disability, marital or veteran status, genetic information or any other characteristic protected by law. In addition, we will provide reasonable accommodations for otherwise qualified individuals requesting an accommodation due to a disability. Loma Linda University Shared Services is a religiously-qualified Equal Opportunity Employer under Title VII of Civil Rights Act of 1964. If you need accommodation assistance with accessing our job listings or completing an application, or during any other phase of employment with us, please contact Human Resources Management at View phone number on click.appcast.io. #J-18808-Ljbffr