Clinical Payment Resolution Specialist
CurrentReview post-billed clinical denials for medical necessity, appealing based on clinical expertise and clinical judgement with the objective of appropriately maximizing reimbursement based upon services delivered and ensuring that the claim is paid in a timely manner. Maintain excellent knowledge of coverage guidelines for multiple payers, commercial and government. Identifies trends and issues affecting reimbursement as it relates to denial prevention. Identify opportunities for process improvement and participate in the implementation of such as needed. Maintains detailed understanding for resolving denial based on patient status, length of stay, level of care, missing pre-certification or other clinical reasons and constructing warranted appeals. Serves as a resource to Payment Resolution Team to help achieve positive operational outcomes.
