Clinical Appeals Consultant – Clinical Validation (CV) – Remote
PayerWatch is a trusted national leader in healthcare revenue recovery. We employ a two-pronged approach
to help hospitals and health systems to achieve better outcomes at a lesser cost. Our Veracity Software
and AppealMasters service assist in preventing and lowering denials and reducing the cost of the claims appeals
process.
Job Title: Independent Medical Reviewer – Clinical Appeals Consultant – Clinical Validation (CV)
Job Summary: The Independent Medical Reviewer is responsible for conducting a timely and comprehensive review
of the medical record and composing a convincing, defensible written appeal letter based on supportive clinical documentation,
authoritative and widely accepted diagnostic standards/criteria, pointed rebuttals to the auditor/payer’s denial rationale, and
evidence-based guidelines and references. The IMR must possess and incorporate into their appeal letters a foundational knowledge
of clinical validation and coding practices as outlined by AHIMA, ACDIS, AHA, and CMS.
Job Type:1099 Independent Contractor Position – This remote position requires a commitment to write a minimum
of ten appeals per week (approximately fifteen to twenty hours per week).
The employee must supply all equipment to work from home in a secure remote environment.
Job Description/Responsibilities and Duties
- Conducts in-depth medical record reviews regarding opportunities for revenue recoupment.
- Provides well-written, grammatically astute appeal arguments based on clinical evidence within the medical record
utilizing formatted templates and incorporating appropriate coding guidelines and coding clinics. - Highlights and/or notates pertinent points in the medical record.
- Provides root cause analyses and performance improvement recommendations to educate clients and identify
process/system issues to mitigate denials. - Must become proficient in understanding and utilizing proprietary Veracity software and templates.
- Completes all task assignments by assigned due dates.
- Ensures compliance with HIPAA and company privacy regulations.
- Attends meetings and completes additional training as requested.
Preferred Knowledge and Skills
- Clinical: Clinical: Possess broad-based knowledge and experience with inpatient medical care
and clinical services and can apply such knowledge to clinically validate and support medical diagnoses
based on authoritative or widely accepted diagnostic standards. - Analytical: Able to extract the worthy components within a medical record to formulate a convincing appeal
based on medical/documentation evidence with a keen ability to refute payer denial rationales using such evidence. - Excellent writing skills: Able to synthesize poorly documented medical records into a compelling written argument to overturn the denial.
- Organization: Disciplined time management and organizational skills.
- Communication: Able to keep supervisor informed of issues and concerns as they arise.
- Quality Commitment: Able to do tasks on time and accurately, consistently strives to better one’s work, can self-edit
to ensure perfect language and spelling, and can put ongoing learning or process changes into practice. - Dependability: The capacity to accept accountability for one’s work product, honor agreements, and voluntarily adhere to
corporate policies and procedures. - Supportive: Committed to the organization’s objectives, client preferences, and agreements with customers and coworkers.
- Integrity: Upholds privacy, defends patients’ rights to dignity, and ensures individual honesty in all business operations.
Qualifications
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) - At least three years of clinical bedside experience required
- At least two years of experience as a Clinical Documentation Specialist with strong knowledge of
clinical quality improvement principles and various consensus-based criteria commonly used for clinical
validation of diagnoses required - Understanding of basic DRG/coding principles
- Knowledge of CMS rules/regulations and third-party payer requirements relative to reimbursable care
- Subject matter knowledge and familiarity with evidence-based inpatient guidelines and criteria
Preferred Experience:
- Foreign or domestic Medical School Graduate (license not required).
ECFMG certification (preferred for Foreign Medical Graduates) - At least one year of experience writing clinical validation appeals strongly preferred but not required
- CCDS, CDIP, and/or CCS certification a plus
Working Conditions
Independent Medical Reviewers work remotely.
How to Apply
Please submit a cover letter, CV or resume, and 2 HIPAA-compliant writing samples to Tracey Tomak at ttomak@payerwatch.com .
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.
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