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Revenue Cycle
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Cottage Health
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190001BJ Requisition #

The Clinical Appeals Writer's role consists of reviewing and appealing for reconsideration medical services that may have been denied or underpaid, either in part or in whole, during the initial claims determination phase.


·         Reviews cases to determine the potential for a provider appeal on denied or underpaid claims. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not Medically Necessary. The clinical review of the denied stays will be evaluated in terms of type, frequency, extent, site and duration of patient’s illness and/or injury or disease.

 

·         Writes requests for reconsideration in an objective narrative form, utilizing appropriate formatting, English grammar, current nationally accepted criteria, medical literature, if applicable, healthcare statutes and prudent clinical judgment. Letters will include appropriate review of the clinical facts and the medically appropriate reasons for reconsideration of the denial or underpayment.

 

·         Forwards letters to the Supervisor of Clinical Denials for review and approval, then sends letters with attached medical records to the payer source for reconsideration. Completes follow-up, as appropriate.

 

 

CERTIFICATIONS, LICENSES, REGISTRATIONS


Minimum: California Registered Nurse license.

 

YEARS OF RELATED WORK EXPERIENCE


Minimum: 5 years nursing experience in an acute care setting.


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