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Denials Prevention Specialist in Alpharetta, GA at CIOX Health

Date Posted: 4/27/2018

Job Snapshot

Job Description

Job purpose


The purpose of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient patient care setting and/or discharge to an alternative level of care. Using nationally recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully.


Duties and responsibilities


  • Responsible for providing timely referral/appeal determination by accurate
  • Usage of the Milliman Care Guidelines and or Interqual
  • Appropriate letter language to author appeal letter
  • Identification of referrals to the medical director for review
  • Appropriate selection of preferred and contracted providers
  • Proper identification of eligibility and healthcare plans
  • Maintaining compliance in turnaround time requirements as mandated by the TAT Standards of the facility and/or CIOX Health Standards
  • Works directly with the provider(s) and health plan Medical Director as needed to facilitate timely authorizations and/or denial reversals
  • Maintains and keeps in total confidence, all files, documents and records
  • Meets or exceeds production and quality metrics
  • Attend all mandatory meetings and trainings
  • All other job-related duties as it relates to job function as delegated by management

Job Requirements

Qualifications: 

  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. List below is representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
    • Two (2) years managed care experience in UM/CM/CDI Department preferred
    • Knowledge of CMS, State Regulations, URAC and NCQA preferred
    • ICD10 and CPT coding a plus
    • Experienced computer skills, Word, Excel, Outlook, experience working in a health plan medical management documentation system a plus.

Minimum Education: LVN/LPN

  • Preferred Education: BA or BS in Nursing, experience preferred to preform
  • Minimum Experience: 3 to 5 years acute care experience2 years Health Plan or Acute Care UR/CM
  • Preferred Experience: 5 years acute care or health plan UR/CM with 1 year ICU/ER