Clinical Appeals Consultant – Medical Necessity (MN) – Remote

Clinical Appeals Consultant – Medical Necessity (MN) – Remote

PayerWatch is a nationwide trusted leader in Healthcare revenue recovery. We use a twofold approach
to equip hospitals and health systems to achieve better outcomes at a lower cost. Our Veracity Software
and AppealMasters service help prevent and lower denials and reduce the cost of the claims appeals

Job Title: Independent Medical Reviewer – Clinical Appeals Consultant – Medical Necessity (MN)
Reports to: Team Lead, Medical Necessity Audit and Appeal Services

Reports to: Team Lead, Coding and Clinical Validation Audit and Appeal Services

Job Type: 1099 Independent Contractor Position – This positions requires a commitment to write a
minimum of ten appeals per week (fifteen to twenty-five part-time hours per week).

Job Description: The Clinical Appeals Consultant – Coding is responsible for completing
government and commercial appeals and related duties, utilizing an encoder and our propriety Veracity software and templates.

Responsibilities and Duties

  • Conducts in depth medical record reviews regarding opportunity for revenue recoupment. Provides well written appeal arguments based on clinical evidence within the medical record plus appropriate Coding Guidelines and Coding Clinics.
  • Highlights and/or notates pertinent points in the medical record.
  • Responsible for proofreading and editing prior to submission.
  • Provides Root Cause analyses and Performance Improvement Recommendations to educate
    and benefit clients.
  • Provides a well thought out appealability score for each appeal.
  • Understands and utilizes Veracity software.
  • Utilizes AppealMaster’s templates according to design.
  • Completes all Task assignments within due dates.
  • Ensures compliance with HIPAA and company privacy regulations.
  • Attends meetings as requested.

Skills and Abilities

  • Clinical: Broad-based knowledge and experience with inpatient and outpatient medical care
  • Analytical: Able to synthesize the worthy components within a medical record and
    formulate a convincing appeal based on evidence.
  • Excellent writing skills: Able to synthesize even poorly documented medical records into a
    compelling written argument to overturn the reimbursement denial using carefully gleaned
    evidence found throughout the medical record.
  • Organized: Disciplined time management skills.

Knowledge, Skills, and Abilities (continued):

  • Able to follow policies and procedures.
  • Communication: Able to keep supervisor informed of issues and concerns as they arise.
  • Provides at least two weeks prior notice of planned leaves. Communication involving
    emergency situations is provided as soon as possible.
  • Commitment to quality: Able to complete work accurately and timely; continuously strives
    to improve personal work product; able to self-edit to ensure flawless grammar and spelling.
  • Dependability: Able to take responsibility for one’s work product and keep commitments.
  • Complete tasks timely or notify supervisor prior to missed deadlines of any barriers to
    meeting deadlines.
  • Time management skills: Able to quickly organize review activities, thoughts, analysis,
    writing, and uploading of completed tasks within assigned time frames.
  • Supportive: Of organizational goals, client desires, and commitments to clients and
  • Integrity: Maintains confidentiality, protects patient dignity, ensures personal integrity in all
    organizational dealings.

Working Conditions

Independent Medical Reviewers work remotely.

QUALIFICATIONS Required Education and Experience

  • Graduate of accredited Nursing or Medical Discipline program with appropriate
    corresponding licensure (RN, NP, CRNP, ARNP, MD, DO, PA, or PA-C)
  • Knowledge and experience with the use of evidence based inpatient guidelines and criteria
  • Knowledge of third-party payer requirements for reimbursable care
  • Knowledge of basic CMS rules and regulations pertaining to reimbursable care
  • Knowledge of basic clinical quality improvement principles
  • At least 5 years clinical experience
  • At least one year on the job experience writing level of care and/or medical necessity

Preferred experience:

  • At least 5 years clinical experience with both adults and pediatric patients
  • Experience with outpatient appeal writing.

How to Apply

Please submit a cover letter, CV or resume, and 2 HIPAA-compliant writing samples to gadams AT Writing samples must be included for consideration.

All qualified applicants will receive consideration for employment, transfer or promotion without regard to race, color, religion, gender, national origin, age, sexual orientation, gender identity, disability, or veteran status.