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, Coding and Clinical Validation Audit and Appeal Services
Job Type: 1099 Independent Contractor Position – This position requires a commitment to write a minimum
of ten appeals per week (approximately fifteen 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
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, along with
payers’ clinical policy bulletins.
- 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 on the prevention of further denials.
- Provides a well thought out appealability score for each appeal, utilizing a scoring rubric provided by PayerWatch.
- Understands and utilizes Veracity software.
- Utilizes AppealMasters’ templates according to design.
- Completes all Task assignments within due dates.
- Ensures compliance with HIPAA and company privacy regulations.
- Attends meetings and additional training as requested.
Knowledge, 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 clinical evidence.
- Excellent writing skills: Able to synthesize even poorly documented medical records and glean
enough evidence to write a compelling written argument to overturn the reimbursement denial or
recommend no appeal warranted.
- Organized: Disciplined time management skills and the ability to work independently and remotely.
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 coworkers.
- Integrity: Maintains confidentiality, protects patient dignity, ensures personal integrity in all organizational dealings.
Independent Medical Reviewers work remotely.
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 medical necessity and have good understanding of authorization requirements for inpatient and outpatient cases
- 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 3 years clinical experience
- At least 3 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 Nancy Herman at firstname.lastname@example.org.
Writing samples must be included for consideration. If writing samples are not available, candidate may be asked to complete a sample appeal for review.
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.