Manages medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
Utilizes clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials.
Responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals.
Review and process appeals submitted by members and providers, ensuring timely and accurate resolution.
Evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times.
Review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24–72 hours.
BlueCross BlueShield of Tennessee has been helping Tennesseans find their own unique paths to good health since 1945. At BCBST, they empower their employees to thrive both independently and collaboratively, creating a collective impact on the lives of their members.
Performs advanced level work related to denial management.
Processes and follows up on all appeal types, at an expert level, to all payers.
Takes actionable steps to resolve open claims, including refiling or appealing claims, or resolving manual tasks.
US Anesthesia Partners is a company that provides anesthesia services. They provide equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, gender identity, sexual orientation, pregnancy, status as a parent, national origin, age, or disability.
Resolve aged claims and appeals via payer portals & outbound phone calls.
Identify non-payment trends and escalate groups of claims to the Dispute Resolution teams.
Propose solutions and collaborate cross-functionally with the Denials Management Steering Committee.
CareDx, Inc. is a precision medicine solutions company focused on healthcare solutions for transplant patients. They offer products, testing services, and digital healthcare solutions. They are the leading provider of genomics-based information for transplant patients.
Take incoming requests for appeals ensuring customer service and maximizing productivity.
Work with appeals team for multiple lines of business ensuring appeal submission for review.
Maintain quality standards, remain current on updated processes, and follow SOPs and HIPAA guidelines.
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans. They have full-service health benefit management solutions to employers, TPAs, and health plans.
Analyze "trigger reports" to identify potential financial exposure early in the claims process.
Gather clinical information to evaluate liability and make recommendations to stakeholders.
Provide cost containment by managing Stop Loss claims and negotiating prices for medical services.
Ullico is the only labor-owned insurance and investment company and has been a partner of the labor movement for over 95 years. The company provides insurance products for members, leaders, and employers, as well as investments.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established guidelines.
Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
Broadway Ventures delivers tailored solutions that drive operational success, sustainability, and growth for government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), they empower clients with expert program management, cutting-edge technology, and innovative consulting solutions.
Responsible for the systematic review of anesthesia records to ensure accuracy, completeness, and compliance with regulatory and institutional standards.
Verifies that all required documentation, provider signatures, and charges are present and appropriately supported.
Plays a key part in supporting quality assurance and regulatory compliance within the anesthesia department and assists with other auditor duties.
Shriners Children’s respects, supports, and values each other. They provide excellence in patient care, embracing multi-disciplinary education, and research with global impact. They were named the 2025 best mid-sized employer by Forbes, fostering a learning environment that values evidenced based practice, experience, innovation, and critical thinking.
Submit clean, timely claims with accurate CPT, HCPCS, ICD-10 codes, and modifiers.
Review provider documentation and assign accurate codes per ICD-10-CM, CPT, and HEDIS/quality reporting guidelines.
Maintain and contribute to the internal billing rules matrix (payer, state, provider type, modifiers).
Imagine Pediatrics is a tech-enabled, pediatrician-led medical group that reimagines care for children with special health care needs. They deliver 24/7 virtual-first and in-home medical, behavioral, and social care. They enhance existing care teams with compassion, creativity, and an unwavering commitment to children with medical complexity.
Performs activities related to insurance company notifications and obtaining certifications/authorizations related to Utilization Review.
Communicates clinical information and updates to insurance companies as requested or required to justify medical necessity.
Liaises with third-party payers regarding UR requirements and assists with complex authorization needs impacting patient transition planning.
Phoebe Putney Health System is southwest Georgia’s preferred career choice for professionals who want to improve the community’s health by joining a respected, cutting-edge team. They are one of the area’s premier employers, offering a close-knit culture, outstanding benefits and many ways to develop your career.