SUMMARY:

Responsible for reviewing and appealing clinical denials, tracking clinical denial trends, identifying continuous improvement opportunities. Responds to any compliance department inquiries requiring clinical expertise.Conducts charge capture reviews as requested by payers, Patient Financial Services, and other TMCH departments to determine opportunities and provide education aimed at improving accuracy of charging practices at Tucson Medical Center (TMC). 

ESSENTIAL FUNCTIONS:

Investigates and analyzes clinical denials and medical records using medical investigative skills to determine if there is support for an appeal based on clinical evidence in the medical record, medical literature and or coding references utilizing TMC’s internal policies and procedures.

Prepares first and all subsequent appeal letters to review companies and/or plan providers. Pursues peer to peer of denials when allowed and appropriate.

Develops and drafts...