- Experience in healthcare authorization and appeals
- Strong understanding of payer processes and medical necessity
- Ability to review, analyze, and resolve authorization/appeal cases
- Strong attention to detail and documentation skills
- Excellent communication and problem-solving abilities
Key Responsibilities
- Clinical Review: Examine medical records, physician notes, and treatment plans to validate medical necessity.
- Criteria Application: Use standard medical guidelines like InterQual, MCG, or CMS regulations (NCD/LCD) to assess level-of-care and authorization denials.
- Appeal Submission: Draft and submit structured, evidence-based appeal arguments to overturn prior authorization and claims denials.
- Peer-to-Peer Coordination: Coordinate and schedule peer-to-peer reviews between attending physicians and payer medical directors.
- Regulatory Compliance