The incumbent is responsible to perform review of denied claims, conducting medical records reviews with use of standardized medical review software, determining claim appealability and initiates formal written or verbal appeals with various health plans. Must have knowledge of medical terminology, various health plan products (Medicare, Medi-Cal, HMO, PPO, Managed Care, etc.) private insurance and CMS guidelines. Previous experience substantiating appeals for Trauma, Acute and Psychiatric services. Also responsible for conducting external charge defense audits requested by insurance companies in collaborating with various audit firms for the conclusion of audits. Performs additional related duties, as assigned.
Annual Rate $69900 $106400 $143000
Ability to establish and maintain effective working relationships across the Health System
Ability to maintain a work pace appropriate to the workload
Must demonstrate customer service skills appropriate to the job
Excellent written and verbal communication skills in English
Competent knowledge and experience with Microsoft Office computer applications, i.e. Word, Excel
Three years' experience working in clinical denial review and/or clinical appeal processing
Three years of related clinical experience in an acute care setting
Five years of internal and/or external audit experience
Familiarity of audit software packages
Must possess the skill, knowledge and ability essential to the successful performance of assigned duties
Must possess a current California RN license
Knowledge of Interqual
Knowledge of University and medical center organizations, policies, procedures and forms
Since 1965, the University of California, Irvine has combined the strengths of a major research university with the bounty of an incomparable Southern California location. UCI's unyielding commitment to rigorous academics, cutting-edge research, and leadership and character development makes the campus a driving force for innovation and discovery that serves our local, national and global communities.