The Itemized Bill Review (IBR) Clinical Appeals Reviewer will analyze and respond to client and/or hospital claim review appeal inquiries. Handles medical record review, analyzes data, and completes the response resolution for clients and the business unit. Must utilize expertise in auditing to review and provide response to appeals. We are seeking self-motivated, solution-oriented and skilled problem solver who provides clinical reviews with written documentation under tight deadlines.
This position is full-time, Monday - Friday. Employees are required to work our normal business hours of 8:00am - 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities
- Analyze scope and resolution of IBR Appeals
- Respond to Level one, two or higher appeals
- Perform complex conceptual analyses
- Identifies risk factors, comorbidities', and adverse events, to determine if overpayment or claim adjustment is needed
- Reviews governmental regulations and payer protocols and / or medical policy to recommend appropriate actions
- Researches and prepares written appeals
- Exercises clinical and/or coding judgment and experience
- Collaborates with existing analysts, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims
- Navigates through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel
- Serve as a key resource on complex and / or critical issues and help develop innovative solutions
- Define and document / communicate business requirements
Required Qualifications
- Undergraduate nursing degree
- Unrestricted RN (registered nurse) license
- 2+ years of appeals experience (coding or auditing)
- Experience with CPT-4 coding, NCCI edit resolution and appropriate modifier use
- Advanced experience with regulations, compliance and composing professional appeal responses
- Advanced experience with ICD10 CM coding and ICD 10 PCS coding
- Willing or ability to work our normal business hours of 8:00am - 5:00pm
- Proven ability to keep all company sensitive documents secure (if applicable)
- Have a dedicated work area established that is separated from other living areas and provides information privacy
- Live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
Preferred Qualifications
- Clinical claim review experience
- Managed care experience
- Investigation and/or auditing experience
- Advanced experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry
- Knowledge of health insurance business, industry terminology, and regulatory guidelines
The hourly pay for this role will range from $35 - $63 per hour based on full-time employment.