The Retrospective Clinical Review & Appeals Specialist is responsible for evaluating and responding to QIO Appeals Requests, Health Plan Appeals Requests and denied claims dispute reconsiderations to ensure appropriate reimbursement and compliance with healthcare regulations. This role involves thorough review of clinical documentation, formulation of appeal letters, and collaboration with healthcare providers and payers to resolve denials effectively.
Key Responsibilities
- Assess denied (no prior authorization) claims dispute reconsiderations for identified agencies by reviewing medical records and determining medical necessity based on clinical review. This team will not review records that have been denied due to administrative denials.
- Documents in tempo the clinical rationale for approving denied claims or sends for physician review and documents outcome, utilizing evidence-based guidelines and payer policies.
- Completes the QIO Appeals process to include requesting information from the agency, reviews documents for medical necessity, reviews NOMNC for validity, outreach to agency based on finding, completes DENC, uploads to the QIO portal, and follow-up for determination.
- Work closely with physicians, case managers, and claims specialists to gather necessary information and support appeal processes.
- Process Health Plan appeals timely and according to company policies and procedures
- Process QIO Appeals timely and according to company policies and procedures
- Ensure all appeals are processed in accordance with federal, state, and payer-specific regulations and timelines.
- Procure and validate NOMNCs needed for appeals
- Create DENCs for all appeals timely and according to CMS and company policies and procedures
- Provide education to providers on NOMNC validity
- Maintain accurate records of all appeal and retro-review activities, decisions, and correspondence in tempo.
- Identify patterns in denials and provide feedback to relevant departments to mitigate future occurrences.
Qualifications
- Graduate from an accredited School of Nursing or Therapy
- Current, unrestricted LPN, RN, OT, PT or SLP license.
- Minimum of 3-5 years of clinical experience, with at least 1-3 years in managed care, utilization review, or appeals and denials.
- Skills
- Strong analytical and critical thinking abilities.
- Excellent written and verbal communication skills.
- Proficiency in medical terminology and coding systems.
- Familiarity with electronic health records (EHR) and appeal tracking systems.
- Ability to work independently and collaboratively in a team environment.
Preferred Experience
- Experience with Medicare and/or Milliman Care Guidelines.
- Knowledge of payer-specific policies and procedures.
- Background in case management or clinical documentation improvement.
Job Type
- Full-time
tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.