What are the responsibilities and job description for the Clinical Validation Appeals Specialist position at Marshall Health Network?
The MHN Clinical Validation Appeals Specialist (part-time/ 20 hours per week) 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 position must possess and incorporate into their appeal letters a foundational knowledge
- Analyze denied claims to identify appealable opportunities based on clinical documentation and payer policies.
- Meet appeal letter response due dates.
- Analyze and interpret regulatory guidelines and Payer contracts.
- Draft concise, persuasive appeal letters using clinical evidence, coding guidelines and MHN internal policies and procedures to support overturned decisions.
- Researches and reviews medical literature an coding references and literature to develop arguments for appeal.
- Develops and drafts documents for administrative hearings in collaboration with relevant MHN staff.
- Prepares witnesses for administrative hearing testimony and attends the hearing with relevant witnesses.
- Based on trends, develops and delivers educational materials to the relevant health care providers, i.e., physicians, nurses, dieticians, and others.
- Communicate with healthcare providers, coders, and revenue integrity teams to gather necessary documentation.
- Participate in strategy meetings to address systemic denial patterns and recommend process improvements.
- Drafts first and all subsequent appeal letters to reviewing companies and/or Plan providers. Pursues Peer to Peer reviews of denials when allowed and appropriate.
- Exhibits excellence in customer service through appropriate attitude and interaction with all patients, visitors, and internal/external customers.
- Maintain up-to-date knowledge of payer requirements, clinical guidelines, and regulatory changes impacting claims.
- Educate clinical and administrative teams on documentation practices to reduce denial rates.
Current RN license.
Minimum of 5 years of experience in clinical documentation improvement.
Proficiency in medical coding systems (ICD-10, CPT).
Exceptional writing and analytical skills.
Ability to work independently and meet strict deadlines in a high-pressure environment.
Experience with electronic health records (EHR) and Microsoft applications.
Work Environment:
This role operates in a remote or hybrid office setting with standard business hours, Monday through Friday.
