Clinical Appeals Coordinator

Overview Job Title: Clinical Appeals Coordinator Location: Central Billing Office, Clinton 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 Associate degree in nursing (ADN) plus five (5) years of clinical nursing experience or a Bachelor’s in nursing plus three (3) years of clinical nursing experience. Utilization review and/or case management experience is preferred. Licensure & Certifications 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. 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. Collects, reviews and performs timely appeals on medical necessity denials and/or authorization denials. Conducts clinical research and analyses and prepares reports as required; anticipates and identifies issues to develop strategies and solutions in the payment and appeals process. Assists with chart audits, reviewing and comparing the medical records against the patient’s itemized bill to ensure complete and accurate revenue integrity. Participates in planning system‑wide measurement initiatives regarding assessment and management of accounts to determine patterns and trends of payment and/or denials and facilitates communication to improve performance and educate management. Assists in review of clinical practice for quality improvement and loss control; recommends appropriate corrective action; reviews for consistency, adherence to policy and comparative level of care in all settings; inputs data and prepares reports. Communicates with clinical and non‑clinical staff regarding findings. Communicates and negotiates with external stakeholders. 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. Physical and Environmental Demands Requires occasional exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold, occasional exposure to bio‑hazardous conditions such as risk of radiation exposure, blood borne pathogens, fumes or airborne particles, and/or toxic or caustic chemicals which mandate attention to safety considerations, occasional working hours significantly beyond regularly scheduled hours, occasional travelling to off‑site locations, occasional work produced subject to precise measures of quantity and quality, occasional bending, occasional lifting and carrying up to 25 pounds, occasional crouching/stooping, occasional kneeling, occasional pushing/pulling, frequent reaching, frequent sitting, frequent standing, occasional twisting, and frequent walking. (occasional‑up to 20%, frequent‑from 21% to 50%, constant‑51% or more) Benefits & Compensation Full‑time, Exempt; Salary; 100% FTE; Day shift; FLSA Designation/Job Exempt: Yes; Pay Class: Salary. Equal Opportunity Employer The University of Mississippi Medical Center is committed to educating the next generation of health professionals, discovering new cures and treatments and providing the highest quality health care. We foster environments that support respect, compassion and belonging for all faculty, staff and students as well as patients and visitors. Our employment, academic, research and clinical care practices reflect these commitments. UMMC is an equal opportunity employer and prohibits discrimination and harassment on the basis of race, color, national origin (including limited English proficiency and primary language), disability, age, sex (as that term is defined in applicable laws such as 45CFR§92.101(a)(2) and binding court decisions), religion, genetic information, veteran’s status and any other status protected by applicable law. UMMC also prohibits retaliation against those who report discrimination or harassment and against those who participate in the Medical Center’s investigation and handling of such reports. Further, UMMC complies with all applicable statutes, regulations and executive orders regarding sex discrimination, sexual harassment, domestic and dating violence, sexual assault and stalking, including but not limited to TitleIX of the Education Amendments of 1972 and its implementing regulations which prohibit discrimination on the basis of sex in any education program or activity UMMC operates including in admission and employment, the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistic Act (“Clery Act”) and the Campus Sexual Violence Elimination Act (“SaVE Act”). UMMC’s commitment to nondiscrimination applies to all of its programs, services, opportunities and activities, including but not limited to all employment, academic, research and clinical care practices and extends to all students, applicants for admission, employees, applicants for employment, affiliates, subcontractors, on‑site contractual staff, third party or community members, visitors to any of our campuses and others participating in UMMC programs or receiving UMMC services. With respect to employment in particular, this commitment applies to all employment decisions including but not limited to recruitment, employment, training, promotion, compensation, benefits, disciplinary actions and termination. UMMC maintains an affirmative action program in accordance with applicable laws. Consistent with these laws, UMMC takes affirmative action to recruit, employ, advance and prevent discrimination against qualified individuals. For additional information, please check here: Know Your Rights: Workplace discrimination is illegal (eeoc.gov). #J-18808-Ljbffr