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Clinical Review Auditor-LPN or RN

Company: Community Health Systems
Location: Sarasota
Posted on: November 22, 2021

Job Description:

Job Description

The Clinical Review Analyst is a professionally Licensed Practical Nurse (LPN) or Registered Nurse (RN) who is responsible for effectively managing the denial/appeal process via the performance of comprehensive analytic reviews of clinical and claim documentation.

This position requires a currentLicensed 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


Maintains a working mastery of industry-standard utilization review criteria (i.e.: Interqual), coverage guidelines, and payor medical policies


Demonstrates knowledge of governmental, managed care, and commercial denial/appeal policies


Appropriately reviews and triages denials for A/R, billing, downgrade, appeal, or denial adjustment


Able to prioritize and manage caseload without jeopardizing timely filing


Demonstrates excellent technical and clinical skills by drafting credible, defensible appeals


Conducts thorough evidence-based clinical literature research to support appeals, as needed


Understands and files appropriate levels of appeal (i.e.: reconsideration, dispute, appeal, ALJ)


Accurately enters data into the Appeal Tracker, Cerner/ClaimIQ/Artiva, or other programs


Notifies department leadership regarding patterns/trends


Together works with department leadership and other Denial Management Team Members to develop and facilitate processes which promote job effectiveness and efficiency


Ability to perform all other duties as assigned or requested


Ensure confidentiality of all patient accounts by following HIPAA guidelines

Keywords: Community Health Systems, Sarasota , Clinical Review Auditor-LPN or RN, Healthcare , Sarasota, Florida

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