Clinical Appeals Specialist

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Responsibilities

The Clinical Appeals Specialist (CAS) is responsible for performing denial reviews for inpatient & outpatient accounts bordering on medical necessity and DRG downgrades as applicable. He/She will review denial letters for Medicare, Commercial and Third-Party payors, interpreting payer denial rationales, crafting custom appeal letters, data entry of audit recommendations, and timely turnaround on appeal letters. CAS is also responsible for identifying payer denial trends, assisting in the creation of appeal rational templates and communicating findings to the management team. He/She will perform other duties as assigned.      

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required Qualifications:

1.     Medical Graduate or Physician Assistant Degree.

2.     Certified Coding Specialist (CCS)

3.     Excellent written and verbal communication skills. Excellent critical thinking skills.

4.     Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred

5.     Basic computer knowledge/experience

Preferred Qualifications:

1.     Master’s degree in Healthcare Administration, Business, Public Health or related healthcare field.

2.     Minimum of two years’ experience with ICD-10-CM and CPT coding in an acute care setting preferred

3.     1+ year of clinical experience in acute care setting preferred.

Pay Transparency

Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $35.00 to $59.85. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

Employment Status

Shift

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

Privacy Notice

Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf