Founded in 1906, McLeod Health is a locally owned and managed, not for profit organization supported by the strength of more than 900 members on its medical staff and more than 2,900 licensed nurses. McLeod Health is also composed of approximately 15,000 team members and more than 90 physician practices throughout its 18-county service area. With seven hospitals, McLeod Health operates three Health and Fitness Centers, a Sports Medicine and Outpatient Rehabilitation Center, Hospice and Home Health Services. The system currently has 988 licensed beds, including Hospice and Behavioral Health. The hospitals within McLeod Health include: McLeod Regional Medical Center, McLeod Health Dillon, McLeod Health Loris, McLeod Health Seacoast, McLeod Health Cheraw, McLeod Health Clarendon and McLeod Behavioral Health.  

Maintains a professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-workers in accordance with our Service Excellence Standards and Core Values. Keep the Service Excellence statement as first item. Responsible for any claim denials regarding medical necessity and authorization and acts as a resource to outside departments relative to the denials process. Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required. Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted. Responsible for governmental payer audits, Medicaid MCO Audits, and Medicare Advantage audits (i.e RAC and Cost Outlier). Provides patterns or trends associated with denials and appeals to Denials Management leadership. Maintains understanding of payer contracts. Maintains clinical competency and current knowledge of regulatory and payor requirements to perform job responsibilities. Collaborates with other departments, such as Case Management and MPA practices, in regards to appeals and denials. Contributes to team effort by accomplishing related results as needed.

Work Schedule: 80 hours bi-weekly

Qualifications /Training:

Working knowledge of managed care terminology, managed care reimbursement methodologies, and billing/coding terminology (i.e. ICD-10, CPT, Revenue Code) preferred. Procedural knowledge of Patient Financial Services. Understanding of basic revenue cycle. Excellent interpersonal, written and organizational skills required. Attention to detail and accuracy skills required. Microsoft Excel and Word knowledge required. Minimum of 2 years healthcare appeals experience preferred

Licenses/Certifications/Registrations/Education:

Must possess a valid RN license