
PHRN – Clinical Denials and Appeals
Job Description
Key Skills
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Job Description
- Effectively review inpatient and/or outpatient medical necessity and authorisation denials to determine and understand the validity of such denials promptly
- Should conduct comprehensive reviews of the claim denial and account to make determinations of what action to take to obtain reimbursement.
- Utilise payer policies, MCG and InterQual criteria to determine if the account meets the criteria for appeal
- Should write an appeal letter to the payer using appropriate clinical indicators, citing Official Coding Guidelines, and documentation from within the patient's medical record
- Perform all other necessary steps on the specified accounts per Client SOP’s including documentation in the EMR, including appeal package creation.
- Manage the accounts until payment is received, the account is written-off, transferred to patient liability, or other adjudication/movement within the system that is appropriate and agreed upon by both Parties
- Reporting quality results, tracking and trending of educational opportunities of the coding and CDI specialists, responding to client subject matter needs, and providing educational support and training
Qualifications:
- PH Registered Nurse with experience in doing medical necessity appeals, lack of authorisation appeals. (6 months needed)
- Proficient in reading Explanation of Benefits (EOB) and investigating denial root causes.
- Must be skilled in navigating various payer and provider portals.
- Typing speed of at least 45 WPM.
- Strong command of the English language, both spoken and written.
- Willing to work night shifts to communicate with payers.
- Familiarity with MCG and InterQual is a plus.
- Must NOT hold a USRN license
Role
Nurse
Timings
Night Shift (Permanent)
Industry
Medical / Healthcare / Hospital
Work Mode
Work from office
Functional Area
Medical Professional / Healthcare Practitioner / Technician
Note: Myglit doesn't charge any money from candidates. If you have been asked to pay money to get this job then report to us immediately at support@myglit.com.

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