- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with ... appeals , ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation,… more
- St. Luke's University Health Network (Allentown, PA)
- …serve, regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- Cognizant (Harrisburg, PA)
- …, and retro-authorization as well as timely filing deadlines and processes. . Review clinical denials including but not limited to referral, preauthorization, ... cycle or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews .… more
- CVS Health (Harrisburg, PA)
- …to determine the accuracy and appropriateness of a benefit/administrative denial. + Can review a clinical determination and understand rationale for decision. + ... issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from… more
- Highmark Health (Monroeville, PA)
- …and contractual requirements. + Documents, monitors, intervenes/resolves and reports clinical denials/ appeals and retrospective payer audit denials. ... outcomes. Interviews and collects patient specified data and chart review related to readmission. + Knowledgeable of and complies...lieu of a degree + 3 years in a clinical nursing role + Current State of PA RN… more
- St. Luke's University Health Network (Allentown, PA)
- …regardless of a patient's ability to pay for health care. The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis ... Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that… more
- CenterWell (Harrisburg, PA)
- …this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review ... An aspect of the role includes an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and… more
- Humana (Harrisburg, PA)
- …this knowledge in their daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, review of ... resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and… more
- Centene Corporation (Harrisburg, PA)
- …with care management teams to optimize outcomes. + Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy ... Assists in the development and implementation of physician education with respect to clinical issues and policies. + Identifies utilization review studies and… more
- Humana (Harrisburg, PA)
- …this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review ... but may not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for… more