Clinical Reviewer Specialist (CRS)

Denial Review & Appeals

• →Demonstrate and consistently apply the Client’s Core Values when interacting with team members, clients, providers, payers, and other stakeholders.
• →Review denied claims to determine the specific denial reason, identify discrepancies, and assess opportunities for appeal.
• →Analyze medical records, clinical documentation, billing records, coding information, and payer correspondence to determine the validity of denials.
• →Research and interpret payer medical policies, reimbursement guidelines, contractual requirements, and applicable regulatory requirements.
• →Apply knowledge of ICD-10-CM/PCS, CPT, HCPCS, modifiers, and other coding principles to identify coding-related denial issues and validate claim accuracy.
• →Evaluate clinical documentation and supporting evidence to determine whether services were appropriately documented and supported.
• →Develop clear, concise, and persuasive appeal arguments supported by clinical evidence, coding guidelines, payer policies, and applicable

Communication & Collaboration

• →Communicates clearly and persuasively, both verbally and in writing, to collaborate with healthcare providers and present appeal arguments.
• →Applies keen attention to detail to ensure accurate review and analysis of denied claims and medical records.
• →Performs other duties as assigned.

• Active certifications – Coding Certifications
• Must have active PHRN; USRN is a plus
• Minimum of 3 years of experience in healthcare revenue cycle management, medical billing, claims processing, or denial management.  
• With IP DRG Coding, Inpatient Surgery Coding, Inpatient E&M / Professional Coding, Inpatient HCC / Risk Adjustment Coding.

• Certified Denials and Appeals Specialist (CDAS) or equivalent denial management credential.
• Experience with EHR systems, such as Epic, and payer denial management portals.