Clinical Appeals Resume Samples

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C Keebler

Christophe

Keebler

371 Mitchell Trace

Detroit

+1 (555) 377 5943

371 Mitchell Trace

Detroit

Phone

p +1 (555) 377 5943

Experience Experience

Philadelphia, PA

Clinical Appeals Supervisor

Philadelphia, PA

Kassulke, Effertz and Hills

Philadelphia, PA

Clinical Appeals Supervisor

Positions in this function are responsible for providing expertise and customer service support to members, customers, and/or providers
Plans, prioritize, organize and complete work to meet established objectives
Coaches, mentors, trains provides feedback, and guides others
May serve as backup in the absence of manager
Works independently
Actively participate in standardization and process improvement
Identifies and solves complex or nonstandard problems on own; proactively identifies new solutions to problems

Chicago, IL

Clinical Appeals Coordinator

Chicago, IL

Bartoletti, Gislason and Rolfson

Chicago, IL

Clinical Appeals Coordinator

Assist in the creation, enhancement and implementation of process workflows for the Complaints and Grievances Department
Interpret Medical Director notes and summarize into correspondence for member, provider and/or facility
Perform clinical education and mentor staff members as necessary
Report trends to management and Network Development for improvement opportunities and provider education
Review and approve Administrative appeals, including retro authorizations and requests that meet medical criteria. (i.e. private duty nursing, DME, behavioral health, experimental and investigational, potential benefit exceptions, cases requiring prior authorization, etc. )
Review and investigate appeals from providers where decisions by the health plan Special Investigation Unit audit process have impacted reimbursement. Determine uphold or overturn of decision
Review first and second level appeals for medical necessity, completes a comprehensive medical necessity packet summarizing clinical facts for the Medical Director review. Coordinates timely case review by a Health Plan Medical Director

present

Philadelphia, PA

Clinical Appeals Specialist

Philadelphia, PA

Quigley, Beahan and Hilll

present

Philadelphia, PA

Clinical Appeals Specialist

present

Work collaboratively with analytics department to create metrics and conduct analysis of appeal and payer level denial issues
Perform Collection QA audits on appeal documentation and report findings/training suggestions to Management
Assist Manager in assigned tasks and projects as necessary
Perform duties as workload necessitates
Consistently reports to work on time and prepared to perform duties of position
Work with guarantors to secure payment on account balances outstanding for clinical reasons
Review medical records and provide clinical justification for air transports that have been denied for various medical necessity reasons

Education Education

Bachelor’s Degree in Nursing With

The University of Texas at Austin

Bachelor’s Degree in Nursing With

Skills Skills

Basic skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
Basic Skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
Basic skills – able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
Ability to formulate strong clinical arguments to support treatment plans
Knowledge of third party payer rules and regulations
Clinical skills - ability to read and interpret medical records
Interpersonal skills – able to work effectively with other employees, patients and external parties
Interpersonal skills - able to work effectively with other employees, patients and external parties
Clinical skills – ability to read and interpret medical records
Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems

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6 Clinical Appeals resume templates

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Clinical Appeals Supervisor Resume Examples & Samples

Positions in this function are responsible for providing expertise and customer service support to members, customers, and/or providers
Direct phone-based customer interaction to answer and resolve a wide variety of inquiries regarding appeals and grievances
Communicates with appropriate parties issues, implications and decisions
Identifies and solves complex or nonstandard problems on own; proactively identifies new solutions to problems
Complex tasks are completed without review by others
Plans, prioritize, organize and complete work to meet established objectives
Actively participate in standardization and process improvement
Coaches, mentors, trains provides feedback, and guides others
May serve as backup in the absence of manager
Coordinates or assigns others' activities
Review/analyze phone support data/metrics and communicate patterns/trends to internal stakeholders, as needed (e.g., leadership, Subject Matter Experts, business partners)
Participate in customer site visits, as needed (e.g., to obtain feedback, provide education, clarify support processes, highlight company performance
1+ year of experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Word, and Outlook
Minimum 1 year experience with claims, appeals or utilization management
Minimum 6-12 months leadership experience
Experience managing in a Call Center Environment
Previous experience with handling claim denials and customer escalations
Familiarity with Behavioral Health terminology

Clinical Appeals Representative Resume Examples & Samples

Cleaning and scrubbing cases received from the E&I Benefit Operations department
Making outbound calls as needed to request missing information or to verify information
Interacting with multiple teams to resolve issues and meet urgent turnaround times
Multitasking in a fast-paced environment
1+ years of experience with Windows applications such as Microsoft Excel, Word and Outlook
6+ months of Telephonic Customer Service experience
Data Entry skills, including a typing speed of at least 45 WPM

Manager of Clinical Appeals Resume Examples & Samples

Attend meetings
Perform ongoing analysis of the team
Define the expectations of day to day activities as opposed to ensuring the day to day work is done
Workflow development for new initiatives and projects
Maintenance of day to day staff performance and assisting the supervisors in action plans when performance is not met
Act as a liaison with internal and external customers
Current RN license
1 plus years management experience

Manager of Clinical Appeals Resume Examples & Samples

Minimum 3 years Supervisory/ Managerial experience required, preferably in a multi-site/multi-state environment
Experience with appeals, and payer reimbursement / contracts
Proven track record of inventory management and account resolution
Proven track record managing staff productivity and quality
Proven track record of successful process improvement in account resolution
***Only applications with salary requirements listed will be considered****

Clinical Appeals Team Lead Resume Examples & Samples

Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by onsistently meeting and exceeding expectations
Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and ystems
Basic skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate roperly, spell correctly and transcribe accurately

Clinical Appeals Specialist Resume Examples & Samples

Monitors insurance denials by running appropriate reports and contacting insurance companies to resolve claims denied for clinical reasons
Identifies coding or clinical documentation issues and works to correct them in a timely manner
PC skills – demonstrates proficiency in Microsoft Office applications and others as required
At least one year case management experience required; relevant education may substitute experience requirement

Clinical Appeals Specialist Resume Examples & Samples

Review and research denials related to clinical or medical necessity issues to determine if second level appeal is warranted
Formulate clinical appeals and letters of medical necessity to be sent to third party payers for inpatient and outpatient services
Submit clinical appeals for off-label drug denials and ensure that all information/criteria required for drug assistance programs are met
Communicate with medical providers to improve and/or clarify documentation in the electronic medical record to support the medical necessity of patient care services
Track and trend all second level appeals to determine number and types of appeals, root cause, success rates and trends, including denials that have been escalated to the Medicare Administrative Law Judge (ALJ)
Assist in the update and maintenance of the clinical appeals database
Analyze data and prepare reports and or summaries as directed
Participate in developing solutions for identified reimbursement issues related to payer medical policies and reimbursement guidelines, including payers and medical providers
Provide a resource to other departments within and outside DFCI to prepare appeals, respond to audits, and support DFCI initiatives
Represent DFCI at ALJ hearings for Medicare denials
Document key business process workflows, policies and procedures
Knowledge of third party payer rules and regulations
Superior written and verbal communications skills to effectively work and communicate with all levels of internal and external staff
Ability to formulate strong clinical arguments to support treatment plans
Must be committed to a customer service philosophy
Ability to work closely and effectively with peers across the organization

Finance Clinical Appeals Coordinator Resume Examples & Samples

Payer Denial Management Nurse: Supports the denial and appeal process within the Payer Denial Management department. Coordinates denial appeal follow-up and analyzes provided clinical documentation, criteria application, physician advisor input, completes review of the medical record and formulates the appeal letter. Participates in the application of medical necessity review and utilizes criteria tool (MCG and/or InterQual). Ensures compliance standards are met with required elements and provides feedback to the management team. Relays physician, nursing and care manager documentation improvement opportunities to assist with appeal defense process
RAC /Payer Audit Nurse: Supports denials, appeals, within the Payer Audit department. Conducts audit reviews to assure activities conform to regulatory requirements. Coordinates denial appeal follow-up; analyzes provided clinical documentation, criteria application outcome, physician advisor input, completes review of the medical record and formulates the appeal letter. Expert in the application of medical necessity review criteria tool (MCG and/or InterQual). Supports the development of performance improvement strategies in response to identified patterns and trends involving government payers
Charge Capture Nurse: Supports the Observation charge capture process for the enterprise. Works with a multi-disciplinary team to evaluate and improve the charge capture process. Reviews the medical record for Observation cases to ensure accurate and timely billing of observation hours and appropriate charges. Utilizes the application of medical necessity review criteria tool (MCG and/or InterQual). Works cooperatively to review, evaluate and improve the charge capture process to establish an enterprise uniform process. Supports development of performance improvement strategies in response to identified patterns and trends
Minimum 3-5 years Care Management or Utilization experience which would include acute med/surg experience required
Expertise with InterQual and Milliman disease management ideologies is preferred
In-depth familiarity with third party billing requirement and regulations, billing documentation requirements preferred. Understanding of CPT and HCPCS coding guidelines preferred

Clinical Appeals Review Coordinator Resume Examples & Samples

Ability to present material in a clear and concise manner that is tailored for the intended audience which may include hospital administration and other hospital professionals is required
Experience in multiple clinical services lines and/or service providers, including IRF, IPF, SNF, CAH and Acute Hospital, preferred
Ability to work in Word Processing software; Spreadsheet software and Database software
Licensed clinical professional (RN, LPN, MSW, PT, OT, etc.) required
Requires the ability to handle multiple tasks, to be organized, and meet deadlines
Requires excellent communication skills, both verbal and written
Clinical license, preferably in nursing
Case management experience either hands on at a hospital level or insurer
Experience with appeals at all levels, preferred
Excellent technical and creative writing skills

Clinical Appeals Specialist Resume Examples & Samples

Basic Skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
Clinical Skills – ability to read and interpret medical records
At least one year of case management experience required

Clinical Appeals Specialist LPN San Antonio Shared Services Center Resume Examples & Samples

Monitor insurance denials by running appropriate reports and contacting insurance companies to resolve claims denied for clinical reasons
Update the patient account record to identify actions taken on the account
Communication -communicates clearly and concisely, verbally and in writing
Customer orientation -establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
Interpersonal skills –able to work effectively with other employees, patients and external parties
PC skills –demonstrates proficiency in Microsoft Office applications and others as required
Policies & Procedures -demonstrates knowledge and understanding of organizational policies, procedures and systems
Basic skills –able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
Clinical skills –ability to read and interpret medical records

Collection Specialist Clinical Appeals Resume Examples & Samples

Calling the insurance company (Heavy phone calls to payers only)
Completing appeals
Banking skills
Working with Windows based software(Excel, PPT, outlook, word)
ONLY CANDIDATES WITH SALARY REQUIREMENTS LISTED WILL BE CONSIDERED***

Clinical Appeals LPN Resume Examples & Samples

Applies regulatory requirements and accreditation standards to all review activity and reporting
Applies accepted criteria to review process, utilizes the parameters and inputs review data into systems
Ensures quality customer service, maintenance of confidentiality, and assistance in identifying process improvement opportunities related to appeals processing
Ensures accurate data entry into the medical management system, including but not limited to appropriate procedure and diagnosis codes, approved abbreviations and relevant clinical information documented per departmental policies
Performs special duties as assigned
Preferred: 2+ years of experience in an acute care clinical setting (medical and/or behavioral health)
Preferred: 2+ years of experience in managed care
Advanced ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate knowledge of community, state and federal laws and resources
Intermediate proficiency in a healthcare management system

Clinical Appeals LSW, Lmhc Resume Examples & Samples

Utilizes WellCare designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with appeal determinations
Collects information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process. Reviews and interprets a variety of instructions and medical notes furnished in written and oral form to determine appropriate action towards appeal
Prepares and submit projects, reports or assignments as needed to meet department initiatives and/or objectives
Produces approval and/or denial letters on behalf of the Medical Director for submission to member, provider or hospital
Required: 2+ years of experience in a clinical setting with general nursing exposure in utilization management (UM), to include pre-authorization, utilization review, concurrent review, discharge planning, case management with review, and/or skilled nursing facility reviews
Advanced knowledge of medical terminology and/or experience with CPT and ICD-9 coding
Intermediate proficiency in Microsoft Outlook, Word, Excel, and PowerPoint
Ability to use a proprietary healthcare management system

Clinical Appeals Coordinator Resume Examples & Samples

Excellent interpersonal skills to interact with internal and external customers
Self-motivated, highly organized, detail oriented, member advocate
Possess excellent oral and written communication skills
Experience with corporate medical policy and procedures, possess a thorough understanding of HMO and PPO benefit structure, demonstrated proficiency in Microsoft Office products, database, spreadsheet software, precertification and claims systems
Ability to work through complex issues

Clinical Appeals Representative Resume Examples & Samples

Receive appeal or grievance documentation and determine relevant details (e.g., what member is requesting)
Make outbound calls to members and/or providers to clarify appeal or grievance information
Determine where appeal or grievance should be reviewed / handled or route to other departments as appropriate
Contact and work with other internal resources to obtain and clarify information
Complete appeal or grievance review procedures according to relevant regulatory or contractual requirements, processes and timeframes
35 wpm Typing skills
Ability to create, copy, edit send & save using Microsoft Office (Word, Excel, & Outlook)
Experience in Claims, Managed Care HMO, Doctor's office, and/or Billing
Medical Terminology experience

Clinical Appeals Specialist Lead-pbs Resume Examples & Samples

Associate’s degree (A.A.) in Nursing or equivalent from two-year college or technical school; and five to seven years’ experience and/or training in the air medical transport industry; or equivalent combination of education and experience
Bachelor’s degree (BS/BA) in Nursing from four-year college or university preferred
Two (2) years’ education and training experience
Ability to participate in regular training and conferences to remain current in knowledge and practice
Knowledge of various Hospital PPO, HMO, Medicare, Medicaid and other payer reimbursement structures
Thorough understanding of claims process
Strong analytical, numerical, and reasoning skills
Advanced customer service and phone skills
Strong teambuilding and leadership skills
Proficient with Microsoft Office Suite including Excel, Word, PowerPoint and Outlook

Clinical Appeals Representative Resume Examples & Samples

35+ WPM typing skills
Ability to create, copy, edit send, and save using Microsoft Office (Word, Excel, and Outlook)
Experience in Claims, Managed Care HMO, Doctor's office, and / or Billing

Clinical Appeals Coordinator Resume Examples & Samples

Assist in the creation, enhancement and implementation of process workflows for the Complaints and Grievances Department
Assist with identifying continuing education needs and opportunities; maintain continuing education and appropriate CEUS required for RN licensure
Create correspondence for review prior to finalizing-outreach to members and/or providers as needed to obtain and review additional clinical documentation
Interpret Medical Director notes and summarize into correspondence for member, provider and/or facility
Manage escalated member and provider issues as required
Perform clinical education and mentor staff members as necessary
Prepare comprehensive Independent Review Entity Packets, including clinical justification of the Medical Director's decision which includes all applicable points from the specific policy, Evidence of Coverage statement and/or documentation submitted to which the decision pertains
Prepare physician consultant review packets for designated specialized services (i.e. Private Duty Nursing) outline case and peer review needs
Report trends to management and Network Development for improvement opportunities and provider education
Respond to members and/or providers in writing with the results of appeal review in accordance with Complaints and Grievances Department standards and all applicable regulatory requirements. Outreach to members and/or providers as appropriate to communicate decision
Review and approve Administrative appeals, including retro authorizations and requests that meet medical criteria. (i.e. private duty nursing, DME, behavioral health, experimental and investigational, potential benefit exceptions, cases requiring prior authorization, etc. )
Review and investigate appeals from providers where decisions by the health plan Special Investigation Unit audit process have impacted reimbursement. Determine uphold or overturn of decision
Review first and second level appeals for medical necessity, completes a comprehensive medical necessity packet summarizing clinical facts for the Medical Director review. Coordinates timely case review by a Health Plan Medical Director
Review, investigate and complete appeals related to medical necessity, appropriate level of service and benefit coverage for all lines of business in required timeframes
Track and trend appeals related to medical necessity, coding issues and other administrative reasons
Work closely with Special Investigations Unit (SIU), Network Development, Claims, Community Care Behavioral Health, Provider Services, Member Services, Medical Management, Benefit Configuration, Compliance, Enrollment, Pharmacy Services, Reimbursement and Coding departments to ensure review processes are understood and meet Health Plan strategy for appropriateness of provider reimbursement as well as quality of care and services
Registered nurse with a minimum of two years direct patient care experience required
Two years of Health Insurance experience as a Registered Nurse in a Utilization Management/Medical Management role strongly preferred
Experience with accountability for regulatory compliance for entities such as NCQA, CMS, Department of Public Welfare, Department of Health and Pennsylvania Insurance Department preferred
Excellent verbal and written communications skills required
Direct experience with physicians or facilities regarding health insurance reviews and reimbursement preferred
Working knowledge of insurance benefit packages preferred
The ability to work in a fast paced insurance environment and to handle multiple priorities/projects in a professional manner required
Working knowledge of ICD-9/ICD-10 and CPT classifications and coding of diagnoses and procedures preferred
Proficiency in computer skills required
Ability to collaborate effectively with physicians and other health care professionals
Strong organizational and problem solving skills with ability to make decisions independently

Clinical Appeals Coordinator Resume Examples & Samples

3 years clinical experience (acute care/hospital)
3 years’ experience case management, utilization review, denial management, audits and appeals, clinical documentation improvement or related experience
Ability to effectively and accurately manage multiple tasks and complex projects in a fast-paced and changing environment
Ability to effectively manage physician relationships
Discretion when dealing with sensitive information
Ability to analyze and apply complex regulations
Proficient in computer applications including MS Office, Excel and PowerPoint
Experience working with electronic health record
Current, unencumbered California RN license
BS degree - RN
Experience working with payer environment
Working knowledge of medical necessity criteria
Certified Case Manager (CCM)
Accredited Case Manager (ACM)
Certified Professional in Healthcare Management (CPHM)

Clinical Appeals Specialist Resume Examples & Samples

Preparation and submission of all levels of appeals
Perform Collection QA audits on appeal documentation and report findings/training suggestions to Management
Work collaboratively with analytics department to create metrics and conduct analysis of appeal and payer level denial issues
Act as a resource to the Center Leadership on submitting appeals, documentation, coding, & clinical account review
Utilize all available resources (i.e., websites, publications, payer and 21C managed care updates, coding policy updates/changes) to assure appeals & documentation processes incorporate most current information to achieve optimum results
Act on suggestions by staff and work with management to enhance productivity and ability to successfully appeal denials
Identify recurring issues with documentation and report back findings to management
Assist with implementation of training workshops on identified needs
Notify management of improper payer behavior trends – such as: denials that do not follow the payer contract or established guidelines for the treatment provided
Notify management of coding or clinical documentation issues that cause denials and appeals that will not result in payment, for communication back to committees for process improvement implementation
Assist Manager in assigned tasks and projects as necessary
Conduct initial and ongoing training with PFS employees and provide clinical and appeal reference materials to maintain current training/reference online library
Interface with employees from other departments and clinical sites to facilitate resolutions to outstanding appeal issues
Responsible for tracking the status of the Peer to Peer process through denial resolution and notification to Medical Director and management
Lead the monthly review of appeals and denials related metrics with Center leadership
Assisting with implementation of new tools, reporting and documentation templates for appeal preparation
Review refund requests and assist with appealing decisions when warranted
Adhere to Company Policy and Procedures
Acts as a role model within and outside the Company
Perform duties as workload necessitates
Maintain a positive and respectful attitude
Communicate regularly with Manager about Department issues
Demonstrate flexible and efficient time management and ability to prioritize workload
Consistently reports to work on time and prepared to perform duties of position
Meets Department Productivity Standards
2 years recent experience with Utilization Review in a hospital or in insurance company setting (Required)
2 years’ experience in oncological setting (Preferred)
General Experience in working with utilization review standards (Preferred)

Clinical Appeals Representative Resume Examples & Samples

Multi - tasking in a fast - paced environment
Candidates must be able to support a Monday through Friday from 9 AM to 6 PM CST shift, with occasional overtime
1+ years of experience with Windows Applications, such as Word, Excel and Outlook; including the ability to create, edit, copy, send and save documents, correspondence and spreadsheets
Strong Data entry skills with the ability to type at least 45 WPM

Clinical Appeals Specialist Resume Examples & Samples

Review medical records and provide clinical justification for air transports that have been denied for various medical necessity reasons
Contact hospitals, bases, Regional Leadership, Emergency Medical Services providers, and any other resources necessary to gather information to support medical justification in clinical appeals
Maintain current Appeal Letter Training Program, and continue to provide support to the Regional Clinical Manager’s and Medical Director’s currently participating in the appeal letter process
Work collaboratively with the Clinical Department, Education Department, and Risk Management to develop a comprehensive documentation training program that focuses on complete, thorough, and specific documentation requirements for all patient care records
Conduct training for both new hires and current Air Methods clinicians employed at both Community Base Services (CBS) and Alternative Delivery Model (ADM) programs
Manage the documentation training program by delegating, and scheduling approved presenters/trainers to attend new hire orientation, or other scheduled trainings or meetings
Communicate data and collection trends with Regional Directors and Regional Clinical Managers within Air Methods to collaboratively discuss, formulate and implement region and/or program specific training
Attend meetings with key customers, insurance groups, and state and local government officials
Conduct training for other Air Methods customers
Ongoing evaluation of clinical justification practices and payer guideline modifications, amending the current training program to correlate with such changes
Strong interpersonal skills and a high degree of collaboration at all levels

Clinical Appeals Specialist Resume Examples & Samples

Communication - communicates clearly and concisely, verbally and in writing. This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately
Technical skills - Professional presentation skills needed to represent facilities in legal issues
Minimum one year of experience in related area required

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