Clinical Review Auditor - REMOTE

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(Full-Time, Remote)

The Clinical Review Analyst is a professionally licensed nurse/LPN who is responsible for effectively managing the denial/appeal process via the performance of comprehensive analytic reviews of clinical and claim documentation. The CRA will perform triage, determine payment viability; and draft and submit credibly defensible appeals (according to payer guidelines) to obtain appropriate reimbursement for care delivered to patients.

As a Clinical Review Analyst at Community Health Systems, you’ll play a vital role in supporting our purpose to help people get well and live healthier by providing safe, quality healthcare, building enduring relationships with our patients, and providing value for the people and communities we serve. Our team members enjoy a robust benefits package including health insurance, flexible scheduling, 401k and student loan repayment programs.

Required

• Experience: Clinical experience in an acute care setting
• Education: High School Diploma; Nursing Degree
• License/Registration/Certification: Must possess current RN/LPN licensure in state of Florida
• Computer Skills: To perform this job successfully, an individual should have knowledge of Word Processing software, Spreadsheet software and E-mail software
• Additional Skill Requirements: Must be detail oriented and current in healthcare pathophysiology concepts. Must be able to multitask and seek answers using online tools.
  
  

Preferred

• Experience: Four to six years related experience; Previous healthcare financial services experience or appeals/denials experience
• Education: Master’s Degree
• License/Registration/Certification: RN Licensure
  
  

Essential Duties And Responsibilities

• Maintains a working mastery of industry-standard utilization review criteria (i.e.: Interqual), coverage guidelines, and payor medical policies
• Demonstrates knowledge of governmental, managed care, and commercial denial/appeal policies
• Appropriately reviews and triages denials for A/R, billing, downgrade, appeal, or denial adjustment
• Able to prioritize and manage caseload without jeopardizing timely filing
• Demonstrates excellent technical and clinical skills by drafting credible, defensible appeals
• Conducts thorough evidence-based clinical literature research to support appeals, as
• needed
• Understands and files appropriate levels of appeal (i.e.: reconsideration, dispute, appeal, ALJ…)
• Accurately enters data into the Appeal Tracker, Cerner/ClaimIQ/Artiva, or other programs
• Notifies department leadership regarding patterns/trends
• Together works with department leadership and other Denial Management Team Members to develop and facilitate processes which promote job effectiveness and efficiency
• Ability to perform all other duties as assigned or requested
• Ensure confidentiality of all patient accounts by following HIPAA guidelines
• This is a remote position.
  
  

We know it’s not just about finding a job. It’s about finding a place where you are respected, valued and where your work is purposeful and fulfilling. A place where your talent is recognized, professional development is encouraged and career advancement is possible.

Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 70 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.

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To Apply, please email [email protected]

Equal Employment Opportunity

This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.