A Clinical Auditor or Utilization Reviewer reviews the efficiency of healthcare delivery. Individuals tend to have had experience as a registered nurse or other healthcare delivery roles before transferring into this quality review role.
•The Coordinator-Clinical Appeals is responsible for the support of the daily function and operations of the Billing and Collections department by reviewing and appealing clinical denials as well as retro authorizations. Interfaces with payors, Case Managers, Insurance Verification department, Financial Counselors, PBO, and Health Information Management department. Reviews medical records for medical necessity of admission, severity of illness, and intensity of service based on InterQual and Milliman Guidelines. Documents in appropriate systems the results of retro authorization and denial or appeal efforts. Reviews referred accounts for appropriate trauma charges, as well as NICU when requested, when charges are inconsistent. Composes and sends appeal letters to payor when denial is in violation of state and federal laws as well as due to lack of sufficient information sent to payor. Evaluates and reviews in-patient hospitalizations for delay of service and delay of discharge. Reviews all findings and appeal letters with Denial Clinical Appeals Unit (CAU) Management. Participates in department quality improvement projects. Performs other duties as needed.
MINIMUM REQUIRED QUALIFICATIONS
•Recent experience in specialty BLS California Vocational Nurse (LVN) license or Medical Terminology certification
PREFERRED QUALIFICATIONS
•Nationally recognized certification in Utilization Management, Utilization Review, Hospital Utilization, Managed Care or Health Care related area
LENGTH OF ASSIGNMENT
•22 weeks
SHIFT / HOURS PER WEEK
•8a-5p SYSTEMS•Epic
START DATE
•ASAP
BENEFITS
Becoming an AMN Healthcare professional gives you the incredible opportunity to gain critical career experience, work with new people, and earn a highly competitive salary—but the perks don't stop there. There are many additional benefits to enjoy, including: Medical, dental and vision benefits Earned time off and paid holidays Paid continuing education time 401(K) retirement planning Short-term disability, life insurance, paid jury duty Access to the largest network of facilities and providers in the country Industry experienced workforce management team Licensure and certification reimbursement
At AMN Healthcare, we strive to be recognized as the most trusted, innovative, and influential force in helping healthcare organizations provide quality patient care that continually evolves to make healthcare more human, more effective, and more achievable. • Estimate of payments is intended for informational purposes and includes hourly wages, as well as reimbursements for meal & incidental expenses and housing expenses incurred on behalf of the Company. Please speak with a recruiter for additional details. Qualified Applicants with arrest or conviction records will be considered for Employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
