• Responsible for investigating and processing appeal requests and authorizations.
• Primary duties include review of prospective, retrospective or concurrent medical records of denied services for medical necessity, as well as processing authorizations.
• Serves as a liaison with marketing, business office and administration of the facilities.
• Coordinates the managed care determinations and distributes information to the marketing and admissions support staff across multiple markets.
• Identifies information needed from the referring hospital to finalize the authorization. Appeals Professional II

(contract) Identify the root cause for clinical claim denial, reviewing medical records against nationally recognized clinical criteria guidelines (InterQual, MCG, NCD/LCD, etc.), using clinical decision making to determine the appropriate actions needed to recover or defend revenue, writing professional appeals in response to denied claims or payer audit requests, and identifying and reporting trends to remediate issues and assist with internal process improvement.

• Reviewed appeals for the Qualified Independent Contractor (QIC) which provides an independent second level determination for Centers for Medicare and Medicaid Services (CMS) based on the documentation, facts, laws, regulations and guidelines.
• Reviewed medical records/case file, writes a reconsideration decision that is clear, concise and impartial and supports the determination made, and documents review.
• Responded to and ensured that all appeal issues raised by the beneficiary, representative, and supplier have been addressed.
• Conducted research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
• Conducted quality reviews as needed.

Conducted daily appeals follow-ups, monitoring denial trends/issues and assisting the Appeals Manager with training of the appeals department, assists with staff communication, providing updates, resolving issues, setting goals, maintaining standards, including performing QA reviews for staff and serves as a subject matter expert (SME).

• Performed audits and a comprehensive problem identification analysis of complex and high dollar cases to identify opportunities for revenue recovery which includes medical necessity, level of care, clinical indicators for proper coding and billing issues.
• Utilized evidenced based criteria and other clinical resources to develop sound and well-supported appeal letters for medical necessity and level of care denials.
• Ensured the adequacy and quality of documentation is compliant with all applicable regulatory guidelines in determining if a denied claim warrants an appeal.
• Conducts chart reviews and abstraction from electronic medical records for compliance with Medicare National Coverage Determination and Local Coverage Determination (NCD/LCD) guidelines, Probes, CERTS, Additional Development Requests (ADR) and Administrative Law Judge (ALJ) audits/ appeals while maintaining knowledge of CMS current regulatory and compliance requirements.
• Reviewed prebill accounts for high dollar procedures to identify authorization, documentation, coding or billing discrepancies prior to submitting the bill to the payor.
• Applied correct coding according to the hierarchy of infusion and injection codes for emergency room and observation charges. Utilization Nurse Management Specialist/Transitional Care Coordinator

Coordinated and performed precertification, out of network precertification, inpatient concurrent review and retrospective review for Medicaid Managed Care enrollees.

• Assessed member's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay were medically appropriate.
• Ensured coordination and continuity of health care for enrollees as they transferred between locations or different levels of care.
• Participated in weekly rounds with Medical Director to discuss high dollar and catastrophic cases.

Answered incoming calls accessed the patient's record via Vitas' proprietary electronic patient charting system.

• Identified the physical, psychological, and spiritual needs of patients/families.
• Assessed and analyzed possible interventions assessed the severity of the need and determined appropriate actions which may include contacting hospice team on call providers.
• Served as the patient/family advocate while communicating with physicians, long term care staff and case managers.
• Documented interactions and provided support for triage on call staff.
• Facilitated the conversion of referrals to admissions through the completion of the intake process via the use of effective phone and customer service skills. Claim Review Specialist/Patient Care Coordinator

• Reviewed and analyzed policyholder claim appeals to ensure proper action was taken.
• Maintained current knowledge of corporate policies, products and department procedures.
• Coordinated utilization of Long-Term Care services based on policyholder need and policy provision of benefits.
• Reviewed and analyzed policyholder appeals to ensure proper action was taken, reviewed medical records, nurse's notes and previous claim history to determine eligibility for previously denied claims.
• Corresponded and followed up with the Illinois Department of Insurance inquiries within a timely manner.
• Acted as point of escalation and team lead for priority Long Term Care Correspondence, Medicare Supplement, Disability and Comprehensive Health Policies (appeals, compliance, legal escalations and other high-profile customer concerns/issues).