Clinical Appeals Advocate

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate cases, devise appeal strategies, collect clinical documentation, and create compelling appeal submissions for both commercial and government payers.

• Engage with patients to clarify appeal strategies, outline their responsibilities, and assist in preparation for hearings when necessary.

• Develop clinical case summaries and enhance documentation for difficult payers or stringent coverage criteria.

• Expedite favorable appeal decisions, negotiate payment rates via letters of agreement, and determine appropriate resolutions when denials are maintained.

• Establish and nurture professional relationships with case managers and medical directors to foster positive patient outcomes.

• Discuss payer policies, coverage criteria, benefit limitations, potential costs, and product information with patients and healthcare teams.

• Ensure compliance with Hillrom and third-party payer policies while upholding quality, compliance, and team contributions.

• Pursue ongoing educational opportunities, assist with workload coverage, and undertake additional duties or projects as assigned.

⛳️ Requirements

• Must possess a Registered Nurse (RN), Respiratory Therapist (RT), or Licensed Practical Nurse (LPN) designation, with active state licensure or certification.

• An associate degree or higher, or equivalent work experience in a relevant clinical or reimbursement field is required.

• A minimum of 3 years of experience in reviewing medical records and obtaining third-party reimbursement is preferred.

• Familiarity with federal, state, and local regulations, including HIPAA requirements and payer guidelines.

• Outstanding written, verbal, and interpersonal communication skills with a strong focus on detail.

• Ability to effectively multitask, prioritize essential responsibilities, and manage time autonomously.

• Strong critical-thinking and problem-solving skills, with a willingness to work independently as well as part of a team.

• Proficient in Microsoft Office and related software tools.

• Candidates must be authorized to work for any employer in the U.S.; employment visa sponsorship is not available.

🏝️ Benefits

• Medical and dental coverage beginning on the first day of employment.

• Basic life, accident, short-term and long-term disability, and business travel accident insurance.

• Employee Stock Purchase Plan (ESPP) offering discounted company stock.

• 401(k) Retirement Savings Plan (RSP) featuring employee contributions and company matching.

• Flexible Spending Accounts.

• Educational assistance programs.

• Paid holidays.

• Paid time off ranging from 20 to 35 days based on length of service.

• Family and medical leaves of absence.

• Paid parental leave.

• Commuting benefits.

• Employee Discount Program.

• Employee Assistance Program (EAP).

• Childcare benefits.

• Reasonable accommodations for individuals with disabilities.