Senior Clinical Appeals Reviewer

Department CC019040 Patient Accounting Job Description Summary The Sr. Clinical Denials Coordinator serves as a Clinical Denials Unit Reviewer responsible for managing and appealing level‑of‑care and medical necessity denials. This role applies clinical judgment, payer policy knowledge, InterQual criteria, and contract language to construct high‑quality appeals and optimize reimbursement outcomes. Conducts clinical appeals for level of care medical necessity denials. Position Responsibilities Communicates effectively with Business Office and Care Management teams to obtain necessary information and assess best course of action. Has command of InterQual criteria and can navigate the application efficiently. Is familiar with contracts and can discern relevant contract language for reviews, applying these into appeals and/or conclusions. Constructs well‑redacted, concise, and eloquent appeals, with rationales supported by clinical data/evidence. Has appropriate command of clinical concepts and is competent performing clinical chart reviews. Periodically follows up on cases, appeals pending decisions, and updates data within the reporting tool accurately and timely. Escalates unfavorable cases needing peer‑to‑peer review and ensures all appeal options are exhausted. Maintains a productivity rate of 5‑10 daily appeals or as otherwise agreed with management. Is familiar with navigating all necessary applications to complete duties, including Epic Hospital Billing, Epic Doc Review, MoreCare, OneContent, InterQual, Availity, Optum, and other payer portals. Ensures appeals are completed timely by following payer policies and appeals processes. Maintains a reporting tool that effectively tracks program outcomes. Identifies trends and reports to management, including recommendations for corrective action. All other tasks as assigned. Qualifications License/Registration/Certification: RN License preferred. Education: Medical School Graduate or Bachelor's Degree required. Experience: Critical Care, Surgery, or Intensive Care patient care experience or two years prior experience in case management, clinical denials appeals/utilization management, or a related field. Benefits Health benefits Life insurance Long‑term disability coverage Healthcare spending accounts Retirement plan Paid time off Pet insurance Tuition reimbursement Employee assistance program Wellness program On‑site housing for select positions and more! #J-18808-Ljbffr Mount Sinai Medical Center