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Clinical Denials

Job Category:

Healthcare / Science

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Close date:


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Job Description and Qualification:

Responsibilities and Duties 

  • Performs retrospective (post-discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. 
  • Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization. 
  • Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process. 
  • Demonstrates proficiency in use of medical necessity criteria sets,MCG and InterQual®, as evidenced by Inter-rater reliability studies and other QA audits. 
  • Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs) Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office. 
  • Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc. 

Additional responsibilities: 

o Serves as a resource to non-clinical personnel 

o Provides CDC leadership with sound solutions related to process improvement 

o Assist in development of policy and procedures as business needs dictate 

o Assists Law Department with any medical necessity reviews as capacity allows up to and 

including attending mediation hearings, other litigation forums, etc.