Clinical Review Auditor

Job Description This position requires a current Licensed Practical Nurse (LPN) or Registered Nurse (RN) license. Essential Duties and Responsibilities (List in order of importance or percentage of time spent on the particular responsibility - High to Low 1. Maintains a working mastery of industry-standard utilization review criteria (i.e.: Interqual), coverage guidelines, and payor medical policies 2. Demonstrates knowledge of governmental, managed care, and commercial denial/appeal policies 3. Appropriately reviews and triages denials for A/R, billing, downgrade, appeal, or denial adjustment 4. Able to prioritize and manage caseload without jeopardizing timely filing 5. Demonstrates excellent technical and clinical skills by drafting credible, defensible appeals 6. Conducts thorough evidence-based clinical literature research to support appeals, as needed 7. Understands and files appropriate levels of appeal (i.e.: reconsideration, dispute, appeal, ALJ ) 8. Accurately enters data into the Appeal Tracker, Cerner/ClaimIQ/Artiva, or other programs 9. Notifies department leadership regarding patterns/trends 10 Together works with department leadership and other Denial Management Team Members to develop and facilitate processes which promote job effectiveness and efficiency 12 Ability to perform all other duties as assigned or requested 13 Ensure confidentiality of all patient accounts by following HIPAA guidelines