Job Details

Job Description

The Clinical Appeals Coordinator works in collaboration with the team of clinicians, coding professionals, physicians and HIM members to increase the team's program awareness, process and program benefits with the goal of decreasing denials, enhancing performance and increasing reimbursement for the health system. This person is a liaison for all government and commercial payer appeals. Coordinates the appeals process, job aides and workflows, participates in data gathering and analysis of reports regarding appeal activity as well as prepares for appeals audits, monitors QI (Quality Improvement) activities of appeals department, and assists in the development of department flows and implementations. Maintains all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes.

Responsibilities

• Coordinates daily operations of the Clinical Appeals Team office and provides support to Clinical Appeal Authors and Leadership. Performs a broad range of clerical/support/reception functions in the department and with other departments including CBO. Ensures that requests for information and services are accurately responded to, in a timely and appropriate manner.
• Reviews and triages denial reasons for justification of clinical appeal. Collaborates with other departments, vendors, and all other internal and external areas as necessary to secure responses for appeals and grievances. Enters all appeals in the software tracking system and tracks appeal resolution.
• Assists in analytical review of data to identify provider claims issues and provides feedback to management regarding trends. Identifies potential quality issues and escalates to the appropriate parties.
• Creates and maintains various departmental reports (CBO, ACM, Rubixis, RAC tracking and others as assigned/requested). Posts and distributes reports as required. Documents Policy and Procedures for department in a PDF or Master Document format.
• Effectively uses all applicable computer and office systems/procedures to coordinate documentation, data, and information for the shift to ensure timely communication and smooth operations. Ensures appropriate inventory of supplies and proper functioning of equipment. Ensures the work area is clean, clutter free, and organized.
• Schedules and coordinates events, training and conferences for the department. Keeps departmental calendar and files documents and prepares memo as necessary.

Qualifications

Southern Cali Hospital Culver City

Required Qualifications:

• High School Diploma
• Two (2) years experience coordinating duties in clinical appeals and/or central billing office with a healthcare system.
• Two (2) years denials management experience working with government and commercial payers
• Must demonstrate customer service skills appropriate to the job
• Must be able to read, write and communicate effectively in English
• Computer literacy and proficiency including Microsoft office suite
• Ability to multitask and prioritize needs to meet timelines
• Ability to maintain flexibility and composure in a constantly changing environment
• Ability to establish and maintain effective working relationships within the organization
• Ability to work independently and with groups, identify potential issues and escalate appropriately

Preferred Qualifications:

• Bachelors Degree

Pay Rate: Min - $20.00 l Max - $26.00

About Us

Southern California Hospital at Culver City has been taking care of generations of Culver City and west LA residents. We are a full-service, acute care hospital with a 24/7 emergency department and nationally recognized patient safety. Now at 420 beds, SCH-CC is a general acute care hospital that utilizes many of the latest medical treatments and technologies. The hospital offers a wide range of inpatient and outpatient acute care services, including an orthopedic center, cardiovascular services, acute rehabilitation, sub-acute care, psychiatric care and chemical dependency programs. Additionally, SCH-CC operates a 24-hour emergency services center, which serves as a paramedic receiving station and is staffed by board-certified emergency physicians and nurse specialists.