UofL Health
Medical Appeals Specialist II, Med Plaza II, 8:00a-4:30p
UofL Health, Louisville, Kentucky, us, 40201
Overview
Medical Appeals Specialist II, Med Plaza II, 8:00a-4:30p — Louisville, KY Join to apply for the Medical Appeals Specialist II role at UofL Health. Location & Shift
Address: 250 E Liberty, Louisville, KY 40202 Shift: First Shift (8:00 a.m. – 4:30 p.m.) Job Description Summary
UofL Health is a fully integrated regional academic health system with nine hospitals, four medical centers, and extensive physician practice locations. The organization is affiliated with the University of Louisville School of Medicine and focuses on transforming the health of communities through compassionate, innovative, patient-centered care. Responsibilities
Prepare strong appeal letters based on clinical documentation, evidence-based guidelines, medical literature (if applicable), healthcare statutes, and payor requirements. Identify, mitigate, and prevent clinical denials related to medical necessity and authorization issues. Review complex patient accounts, analyze medical records to formulate compelling clinical arguments, and support pre-claim edits and pre-/post-payment audits by insurers or third-party vendors. Interact with internal customers including hospital staff and physicians to support denial resolution and ensure efficient appeal submissions. Collaborate with Payor Relations and Contracting during contract negotiations and settlements impacting payment variances. Essential Functions
Utilize clinical knowledge to ensure appropriate interventions and adherence to standard of care (e.g., Milliman Care Guidelines, InterQual). Ensure documentation supports credibility of appeals and aligns with payer requirements. Prepare appeal letters using clinical documentation and applicable guidelines to address denial issues such as post-discharge medical necessity, DRG validations, retroactive prior authorizations, and RAC/audit findings. Analyze medical records or documentation to determine appeal potential and validate billed charges (tests, supplies, drugs). Communicate with physicians and interdisciplinary team members to strengthen appeals. Qualifications
Education: Licensed/certified healthcare professional (e.g., LPN, RN, OTR) required; Bachelor’s degree in a clinical field (BSN) preferred. Experience: 3–5 years of clinical experience required; experience with appeals/denial processing and hospital-based clinical background preferred. Licensure: Active, unrestricted registered clinical license (required). Certification: CCM, CPUM, or other relevant certification preferred. Knowledge, Skills, and Abilities: Medical terminology, knowledge of InterQual and Milliman guidelines, critical thinking, strong written/spoken communication, advanced MS Office, project management from start to finish. Language: Proficient verbal and written communication in English. Reasoning: Ability to read/interpret documents, analyze data, and interpret remittances/EOBs/EOPs. Computer Skills: Proficiency in MS Excel, Word, Outlook; comfortable with electronic filing systems. Additional Responsibilities
Maintain confidentiality and comply with all policies, procedures, and safety guidelines. Demonstrate service, teamwork, and professionalism; collaborate with physicians and staff; support denial prevention efforts. Perform other duties as assigned. UofL Health Core Expectations
Live values of honesty, integrity, and compassion; deliver excellent patient care. Honor dignity, ensure quality of care, work as a team, seek feedback, and continuously improve. Use resources wisely and understand how each role contributes to the organization’s success.
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Medical Appeals Specialist II, Med Plaza II, 8:00a-4:30p — Louisville, KY Join to apply for the Medical Appeals Specialist II role at UofL Health. Location & Shift
Address: 250 E Liberty, Louisville, KY 40202 Shift: First Shift (8:00 a.m. – 4:30 p.m.) Job Description Summary
UofL Health is a fully integrated regional academic health system with nine hospitals, four medical centers, and extensive physician practice locations. The organization is affiliated with the University of Louisville School of Medicine and focuses on transforming the health of communities through compassionate, innovative, patient-centered care. Responsibilities
Prepare strong appeal letters based on clinical documentation, evidence-based guidelines, medical literature (if applicable), healthcare statutes, and payor requirements. Identify, mitigate, and prevent clinical denials related to medical necessity and authorization issues. Review complex patient accounts, analyze medical records to formulate compelling clinical arguments, and support pre-claim edits and pre-/post-payment audits by insurers or third-party vendors. Interact with internal customers including hospital staff and physicians to support denial resolution and ensure efficient appeal submissions. Collaborate with Payor Relations and Contracting during contract negotiations and settlements impacting payment variances. Essential Functions
Utilize clinical knowledge to ensure appropriate interventions and adherence to standard of care (e.g., Milliman Care Guidelines, InterQual). Ensure documentation supports credibility of appeals and aligns with payer requirements. Prepare appeal letters using clinical documentation and applicable guidelines to address denial issues such as post-discharge medical necessity, DRG validations, retroactive prior authorizations, and RAC/audit findings. Analyze medical records or documentation to determine appeal potential and validate billed charges (tests, supplies, drugs). Communicate with physicians and interdisciplinary team members to strengthen appeals. Qualifications
Education: Licensed/certified healthcare professional (e.g., LPN, RN, OTR) required; Bachelor’s degree in a clinical field (BSN) preferred. Experience: 3–5 years of clinical experience required; experience with appeals/denial processing and hospital-based clinical background preferred. Licensure: Active, unrestricted registered clinical license (required). Certification: CCM, CPUM, or other relevant certification preferred. Knowledge, Skills, and Abilities: Medical terminology, knowledge of InterQual and Milliman guidelines, critical thinking, strong written/spoken communication, advanced MS Office, project management from start to finish. Language: Proficient verbal and written communication in English. Reasoning: Ability to read/interpret documents, analyze data, and interpret remittances/EOBs/EOPs. Computer Skills: Proficiency in MS Excel, Word, Outlook; comfortable with electronic filing systems. Additional Responsibilities
Maintain confidentiality and comply with all policies, procedures, and safety guidelines. Demonstrate service, teamwork, and professionalism; collaborate with physicians and staff; support denial prevention efforts. Perform other duties as assigned. UofL Health Core Expectations
Live values of honesty, integrity, and compassion; deliver excellent patient care. Honor dignity, ensure quality of care, work as a team, seek feedback, and continuously improve. Use resources wisely and understand how each role contributes to the organization’s success.
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