Spec. Denials and Appeals

University Medical Center Of El Paso - El Paso, TX

Full-time - Mid Level

El Paso, TX

Hospitals

About the position

The Clinical Documentation/Appeals Specialist at University Medical Center of El Paso is responsible for managing denied claims from commercial and contracted payers. This role involves validating and following up on claims, communicating with third-party reviewers, and maintaining the appeal process from denial to resolution. The specialist will ensure that all necessary documentation is obtained and clarified to support the appeal process effectively.

Responsibilities

• Follow up on denied claims from commercial and contracted payers.
• Perform timely validation and follow-up for assigned patients.
• Communicate with third-party nurse reviewers regarding missing or unclear medical record documentation.
• Maintain the appeal process from the denial stage through final denial or overturned appeal.

Requirements

• Bachelor's degree in Business Administration, Healthcare Management, or a related field required.
• Two years of experience with clinical documentation, chart reviewing, utilization review, managed care, and/or claims denials and appeals processing required.
• Knowledge of ICD coding and MS-DRG.
• Knowledge of claims denials and appeals processing.
• Working knowledge of DRGs and medical necessity criteria.
• Advanced communication and interpersonal skills with all levels of internal and external customers.
• Excellent written/verbal communication, critical thinking, creative problem-solving, and conflict management skills.
• Strong organizational and planning skills.
• Proficient in computer skills, including spreadsheets, presentation programs, word processing, and Internet searching.
• Working knowledge of quality improvement theory and practice.
• Knowledgeable of Federal, State, and other payers' regulations, requirements, and criteria.

Nice-to-haves

• Certified Clinical Documentation Specialist preferred.