Managed Resources, Inc.
Purpose
The Clinical Appeals and CDI Specialist uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation. This position works collaboratively with service lines to ensure that the clinical information within the client files/records are accurate, complete, and compliant.
This role provides nurse consultation services that consist of reviewing and appealing for reconsideration of medical services that may have been denied, either in part or in whole, during the initial claims’ determination phase. It also provides education consultation services, including support of nurse education, client education, and consumer education through company webinars and seminars.
Reports to DRG Appeals/CDI Manager
Essential Functions
Review the cases, and determine the potential for a Provider Appeal, on the denied claim.
Write quality appeal letters to achieve maximum overturn rate.
Perform root cause data analysis on diagnoses, medical services, medical codes, and other indicators from reports and other tools.
Review medical documents such as surgical reports, medical visits, and diagnostic reports in order to create educational strategies to ensure correct diagnosis code assignment by the client.
Review clinical documentation and assign accurate diagnosis codes according to guidelines and project.
Perform coding and appeals compliance audits.
Be able to identify opportunities in diagnosis coding, clinical documentation, and billing within the client’s day-to-day operations.
Support on-going educational interventions to clients and staff to close gaps or related data.
Support training in the form of white papers and webinars to clients, targeted groups and staff members.
Perform initial reviews, concurrent reviews and retrospective reviews to ensure there is adequate supporting documentation.
Maintain integrity and compliance in all chart reviews and CDI documentation and queries at all times.
Identify opportunities to improve client documentation and query clients to ensure that appropriate documentation appears in the medical record.
Follow each query through to closure including complete documentation of ongoing follow up activities and communication.
Assist with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause.
Develop and support strong professional relationships with clients and staff members.
Assist in special department projects or other needs as determined by service line department heads.
Enhance department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
Facilitate clarity of clinical information used for measuring and reporting which incorporates current DRG methodologies and/or other regulating/quality reporting bodies.
Perform other duties relevant to the position.
Education and Experience
Bachelor of Science in biology, nursing, business administration or related to the health industry from an accredited school.
RN and Certified clinical documentation specialist credentials CDIP or CCDS (required).
Certification in Case Management, Legal Nurse Consulting, or Coding is a plus.
Certificated coder (preferred) with at least 3+ years of experience in medical coding, medical billing, medical record reviewing, drug or provider representative experience. Recognized certifications by the American Academy of Professional Coders (AAPC) or American Health Information Management (AHIMA). These are: CRC, CPC, CIC, COC, CPC-P, CPMA, CDEO, CCS, CCS-P, CDIP, RHIA or RHIT.
3+ years’ experience in clinical documentation improvement.
Five years of acute hospital experience required.
Working knowledge of billing codes, Revenue Codes, CPT’s, etc.
Experience and knowledge of managed care contracts, account receivables and revenue cycle functions.
Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards.
Experience and success in appealing managed care denials and underpayment decisions.
#J-18808-Ljbffr
This role provides nurse consultation services that consist of reviewing and appealing for reconsideration of medical services that may have been denied, either in part or in whole, during the initial claims’ determination phase. It also provides education consultation services, including support of nurse education, client education, and consumer education through company webinars and seminars.
Reports to DRG Appeals/CDI Manager
Essential Functions
Review the cases, and determine the potential for a Provider Appeal, on the denied claim.
Write quality appeal letters to achieve maximum overturn rate.
Perform root cause data analysis on diagnoses, medical services, medical codes, and other indicators from reports and other tools.
Review medical documents such as surgical reports, medical visits, and diagnostic reports in order to create educational strategies to ensure correct diagnosis code assignment by the client.
Review clinical documentation and assign accurate diagnosis codes according to guidelines and project.
Perform coding and appeals compliance audits.
Be able to identify opportunities in diagnosis coding, clinical documentation, and billing within the client’s day-to-day operations.
Support on-going educational interventions to clients and staff to close gaps or related data.
Support training in the form of white papers and webinars to clients, targeted groups and staff members.
Perform initial reviews, concurrent reviews and retrospective reviews to ensure there is adequate supporting documentation.
Maintain integrity and compliance in all chart reviews and CDI documentation and queries at all times.
Identify opportunities to improve client documentation and query clients to ensure that appropriate documentation appears in the medical record.
Follow each query through to closure including complete documentation of ongoing follow up activities and communication.
Assist with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause.
Develop and support strong professional relationships with clients and staff members.
Assist in special department projects or other needs as determined by service line department heads.
Enhance department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
Facilitate clarity of clinical information used for measuring and reporting which incorporates current DRG methodologies and/or other regulating/quality reporting bodies.
Perform other duties relevant to the position.
Education and Experience
Bachelor of Science in biology, nursing, business administration or related to the health industry from an accredited school.
RN and Certified clinical documentation specialist credentials CDIP or CCDS (required).
Certification in Case Management, Legal Nurse Consulting, or Coding is a plus.
Certificated coder (preferred) with at least 3+ years of experience in medical coding, medical billing, medical record reviewing, drug or provider representative experience. Recognized certifications by the American Academy of Professional Coders (AAPC) or American Health Information Management (AHIMA). These are: CRC, CPC, CIC, COC, CPC-P, CPMA, CDEO, CCS, CCS-P, CDIP, RHIA or RHIT.
3+ years’ experience in clinical documentation improvement.
Five years of acute hospital experience required.
Working knowledge of billing codes, Revenue Codes, CPT’s, etc.
Experience and knowledge of managed care contracts, account receivables and revenue cycle functions.
Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards.
Experience and success in appealing managed care denials and underpayment decisions.
#J-18808-Ljbffr