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Clinical Review Auditor

Company: Community Health Systems
Location: Sarasota
Posted on: February 23, 2021

Job Description:

The Clinical Review Analyst is a professionally licensed nurse/LPN who is responsible for effectively managing the denial/appeal process via the performance of comprehensive analytic reviews of clinical and claim documentation. The CRA will perform triage, determine payment viability; and draft and submit credibly defensible appeals (according to payer guidelines) to obtain appropriate reimbursement for care delivered to patients 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. 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 This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to to obtain the main telephone number of the facility and ask for Human Resources. CHS---and Community Health Systems are tradenames/trademarks of Community Health Systems Professional Services Corporation, which provides management services to affiliates of Community Health Systems, Inc. The terms "Community Health Systems," "CHS," the "Company," or the "organization" refer to Community Health Systems, Inc. and its affiliates including Community Health Systems Professional Services Corporation, unless otherwise stated or indicated by context. The term "facilities" refers to entities owned or operated by subsidiaries or affiliates of Community Health Systems, Inc. References herein to "employees" or to "our employees" or "we" refers to employees of affiliates of CHS Inc.

Keywords: Community Health Systems, Sarasota , Clinical Review Auditor, Accounting, Auditing , Sarasota, Florida

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