Clinical Appeals Analyst

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🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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PAM Health

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

👥 B2C

B2C

PAM Health is a U. S. -based post-acute care provider operating 70+ hospitals and clinics that specialize in inpatient rehabilitation, long-term acute care (LTACH), outpatient rehabilitation, hospice, home health, and behavioral health. The organization provides a range of clinical programs and therapies—physical, occupational and speech therapy, comprehensive wound and amputation care, hyperbaric oxygen therapy, exoskeleton-assisted rehab, and specialized brain and spinal cord injury programs—focused on recovery, clinical excellence, and patient-centered care for complex medical and rehabilitative needs.

📋 Description

• Review patient medical records and utilize clinical and regulatory knowledge and skills, as well as, knowledge of payer requirements to determine why cases/claims are denied and complete an appeal. • Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments. • Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory guidelines to prepare the response to the payer in an effort to overturn the denial in a professional and concise manner. • Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory guidelines to prepare for an Administrative Law Judge hearing and participate in hearings by providing testimony, as necessary. • Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Actively seek out opportunities for appeal by reviewing all insurance denials within assigned region. • Prepare data and analytics and share with the Director and Executive Team and provide feedback to hospitals regarding trends in denied claims. • Discuss documentation-related and level of care decisions with hospitals, independently, as required. • Have the ability to proficiently read, understand and communicate in writing abstract information from patient medical records in a professional manner. • Ensure compliance with HIPAA regulations, including confidentiality, as required.

🎯 Requirements

• Five years’ experience as a clinical nurse in an acute care setting • Current state-issued RN license • Clinical social worker or PTA in lieu of RN license and clinical experience is acceptable as qualification for acquired employees • Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse, Social Worker, or PTA in an acute care setting. • At least two to three years of experience in case management, discharge planning, and/or utilization review is preferred. • Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by auditors. • Knowledge in areas such as InterQual Level of Care and Milliman & Robertson criteria. • Knowledge of third party payer regulations related to utilization and quality review is preferred. • Knowledge of MAC, RAC, ZPIC denials and process. • Ability to travel as required.

🏖️ Benefits

• Competitive pay • Generous paid benefit time • Excellent insurance options • Opportunities for professional growth through our Education Advancement Program