Clinical Appeals Resume Sample

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Eloise DuBuque
6821 Tomas Streets,  San Francisco, CA
+1 (555) 485 6968

Work Experience

Clinical Appeals Specialist
03/2016 - PRESENT
Houston, TX
  • Three years’ experience in healthcare financial billing and accounts receivables management
  • Works with the Clinical Appeals Supervisor, Central Appeal Unit Physician Advisors, and other team members to research, develop and maintain a structured standardized process for writing medical necessity appeals
  • Conducts thorough evidence based clinical literature research as needed to support appeal processes
  • Maintains, through Compliance 360 software, tracking of all appeals stages
  • Monitors and meets appeals timelines for timely submission of appeals to fiscal intermediaries
  • Works with clerical support and hospital staff to obtain medical records, documentation and required supporting information to write appeals
  • Maintains a working mastery of the use of InterQual criteria
  • Maintains current up to date knowledge of the legislative and CMS current trends in governmental revenue integrity audits and other denial processes
  • Provides education and support to hospitals when assigned
Clinical Appeals Coordinator
12/2008 - 11/2015
Houston, TX
  • Assists the Clinical Appeals Supervisor in providing feedback to CHS corporate and facilities regarding current results
  • Assist the Clinical Appeals Supervisor with maintaining physician and hospital specific reports quarterly
  • Maintain current Appeal Letter Training Program, and continue to provide support to the Regional Clinical Manager’s and Medical Director’s currently participating in the appeal letter process
  • Perform authorization audits on incoming denials, appeal documentation and report findings/training suggestions to Management
  • Perform reporting and analysis of appeal and payer level denial issues affecting the authorization process and collections
  • Act as a resource to the verifiers on documentation, coding & clinical account review
  • Track Appeals to provide information to management
  • Utilize all available resources for optimum achievements, (i.e., FCAS Worktool, Websites, Publications, payer and 21C managed care updates, coding policy updates/changes and apply these changes to the appeals & documentation process
Clinical Appeals Review Coordinator
10/2005 - 10/2008
New York, NY
  • Assist as needed scheduling/coordinating Peer to Peer between 21st Century Radiation Oncologist and payer physician
  • Act on suggestions by staff and work with management to enhance productivity and ability to successfully appeal denial of authorizations
  • Continuously communicate Website/Resource tool updates/changes to team
  • Assist with new training by providing resources for training
  • Assist Supervisor in assigned tasks and projects as necessary
  • Conduct initial and ongoing training with employees and provide clinical and appeal reference materials to maintain current training/reference online library
  • Work to keep all reference and training materials updated with any new technology being performed
  • Generate and prepare routine reports from the peer to peer tracking system


Indiana Wesleyan University - Cincinnati Education Center
2000 - 2005
Bachelor's Degree in Management

Professional Skills

  • Strong written skills needed and strong follow-up skills necessary
  • Efficiently manage multiple tasks, prioritize and maintain good time management skills
  • Efficiently manage multiple tasks, prioritize and maintain good time management skills
  • Intermediate Microsoft Suite skills, including Outlook, Word, and Excel
  • Acquired skills with Microsoft Excel, Word, and PowerPoint
  • Experience case management, utilization review, denial management, audits and appeals, clinical documentation improvement or related experience
  • Strong experience in medical government and commercial collections

How to write Clinical Appeals Resume

Clinical Appeals role is responsible for health, insurance, research, reporting, payroll, database, training, government, legal, english.
To write great resume for clinical appeals job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Clinical Appeals Resume

The section contact information is important in your clinical appeals resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Clinical Appeals Resume

The section work experience is an essential part of your clinical appeals resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous clinical appeals responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular clinical appeals position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Clinical Appeals resume experience can include:

  • Effectively utilize Microsoft Word, Excel e-mail, copy and fax machines and other commonly used office machinery
  • Strong experience in Government collections
  • Strong experience in Commercia collections
  • Triage incoming inventory for the Appeals team, validating appeal criteria is met
  • Clinical nursing and/or case management experience
  • Assures the denials database is accurate and remains up-to-date; organize and prioritize data input into this system

Education on a Clinical Appeals Resume

Make sure to make education a priority on your clinical appeals resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your clinical appeals experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Clinical Appeals Resume

When listing skills on your clinical appeals resume, remember always to be honest about your level of ability. Include the Skills section after experience. Present the most important skills in your resume, there's a list of typical clinical appeals skills:

  • Interpersonal skills sufficient to communicate effectively with a variety of clinicians, hospital personnel, and well as third party reimbursement personnel
  • Manage daily activities related to PAS Clinical Appeals function, ensuring processes are performed efficiently and effectively
  • Experience in a clinical, health insurance, coding/claims review or case management setting
  • Two (2) years’ education and training experience
  • Solid proficiency with Microsoft Excel, PowerPoint and Word
  • Current, unencumbered California RN license strongly desired

List of Typical Experience For a Clinical Appeals Resume


Experience For Clinical Appeals Specialist Resume

  • Proficient knowledge of diagnosis coding and sequencing guidelines
  • General knowledge of healthcare revenue cycle including familiarity with reimbursement methodology, charge capture and billing processes
  • Properly identify denial type and category to ensure appropriate management of audits and denials
  • Obtains necessary information needed to complete an audit/appeal; ensures timely responses and updates in all required systems
  • Work in conjunction with Patient Financial Services (PFS) to reconcile denial payments and recoupments in the denial database
  • Coordinates timely medical record and claims reviews with the facilities
  • Collaborate closely with the payers, vendors, Appeals Nurses, Coding Integrity Team, and regional Audit Coordinators to assure they are informed regarding appeal decisions, denials and recoupments

Experience For Clinical Appeals Coordinator Resume

  • Provides feedback to members of the healthcare team (health information management (HIM), case management, PFS, etc.) regarding charging, documentation, patient status and coding issues so changes can be made to prevent future revenue risk
  • Works with corporate department and leaders, communicating information regarding payer activities and outcomes as needed on specific cases
  • Monitors and assures compliancewith all policies, procedures and standards as promulgated by state and federal agencies, the facilities, and other regulatory entities
  • Monitors and assures accuracy of all information in communications and data base administration
  • Knowledge of Milliman (MCG), Interqual or other admission guideline tools

Experience For Clinical Appeals Review Coordinator Resume

  • Proficiency in Cerner electronic medical record
  • Compose technical denial arguments for reconsideration, including both written and telephonically Identify contract protection that can be leveraged to overturn denials
  • Compose technical denial arguments for reconsideration, including both written and telephonically
  • Perform basic math to ensure accurate statement of accounts receivable
  • Meet the productivity and quality standards of the organization
  • Timely completion and comprehension of all educational requirements

List of Typical Skills For a Clinical Appeals Resume


Skills For Clinical Appeals Specialist Resume

  • Previous experience working with Insurance Clinical Appeals
  • Previous SCIIDRS, IDRS, ECAA, ETS, IQ, systems experience
  • Knowledgeable and/or previous experience in Medicare Recovery Audits and managed care audit processes
  • Take initiative; be self directed and exercise consistently sound judgment in making appropriate decisions regarding denials and appeals
  • Perform reporting and analysis of appeal and payer level denial issues affecting collections
  • Act as a resource to the collectors on submitting appeals, documentation, coding & clinical account review
  • Adapt to new or consistently challenging problems, procedures, and policies
  • Organize workflow and self-direct while operating within a defined workflow
  • Read and understand Health Care Financing Administration (HCFA) regulations, i.e. Payer Updates

Skills For Clinical Appeals Coordinator Resume

  • Read and understand Health Care Financing Administration (HCFA) regulations, i.e. Medicare Updates
  • Normal or corrected vision and hearing to normal range
  • Clinical understanding of Radiation Oncology, ICD-9, CPT and medical terminology
  • Clinical understanding of Radiation Oncology, ICD-9 and/or ICD-10, CPT and medical terminology
  • Understands the difference in billing, collections, payments, and refunds for governmental, managed care, and commercial payers

Skills For Clinical Appeals Review Coordinator Resume

  • Possess an understanding of accounts receivables and claim denials
  • Answer questions from staff regarding issues of medical necessity
  • Review appeal letter requested report and ensure all timely filing is met
  • Licensed as a Registered Nurse (RN) in the State of Maine
  • Current knowledge of the rules and regulations as they relate to State and Federal Government and 3rd Party Payors. Including an in depth understanding of Medicare’s LCD and NDC medical necessity guidelines, appeals process and timelines
  • Knowledge of broad range of medical and psychiatric diagnoses, current treatment modalities, therapeutic service and intervention techniques
  • Work under pressure, and to maintain patience in difficult situations as well as to cope with a high volume work load
  • Familiarity with medical records, health information management systems
  • Work independently yet also be part of the Radiation Therapy Services, Inc. (R.T.S.I.) team

Skills For Clinical Appeals LPN Resume

  • Identify, communicate and coordinate resolution for appeal and documentation issues
  • Attend to detail and track accounts and projects through to completion
  • Receive and follow instruction
  • Understand the role in relationship to the entire revenue cycle
  • Document accounts and appeal letters clearly
  • Analyze accounts, procedures and insurance contracts and updates
  • Articulate education in oral and written form and convey clearly to the intended audience
  • Use Microsoft Excel, PowerPoint and Word

Skills For Clinical Appeals Specialist Lead-pbs Resume

  • Focus and successfully meet goals set by Management
  • Able to work 8 hours per day M-F with occasional overtime when needed
  • Work independently yet also be part of the Patient Financial Services team
  • Identify, communicate and coordinate resolution for collection appeal and documentation issues
  • Read and understand different Explanation of Benefits (EOBs)
  • Document accounts and appeal letters clearly
  • Analyze accounts, procedures and insurance contracts and updates

Skills For Manager of Clinical Appeals Resume

  • Adhere to policy and procedures set company wide and inter-departmentally
  • Experience using a computer and Microsoft Office - Microsoft Word (create correspondence and work within templates), Microsoft Excel (data entry, sort, filter, and work within tables), and Microsoft Outlook (email and calendar management)
  • Leadership - guides individuals and groups toward desired outcome by providing training, advice and feedback to assist/support employees in achieving established performance standards
  • Previous experience working with Microsoft Office including Microsoft Outlook (ability to create, edit, save, and send documents), Microsoft Word (ability to create, edit, save, and send documents), and Microsoft Excel (ability to create, edit, save, and send spreadsheets)
  • Manage recurring coding or clinical documentation issues and correct the underlying causes for errors
  • Analyze trends in insurance denials and work with insurance companies to resolve underlying reasons for denials
  • Analytical and able to work through complex issues
  • Perform Q/A for Clinical Appeals function
  • Screen, interview, and hire new employees

Skills For Clinical Appeals Specialist LPN San Antonio Shared Services Center Resume

  • Counsel staff with disciplinary and productivity issues
  • Work as a liaison between the Clinical Appeals staff and other Patient Account Services staff
  • Resolve issues escalated by Clinical Appeals staff
  • Current State RN or LPN licensure required
  • Microsoft Office, Word, Excel and PowerPoint

Skills For Clinical Appeals LSW, Lmhc Resume

  • Current State LPN or RN license
  • Understand account reimbursement and receivables management
  • Licensed as a Registered Nurse (RN) in the State of Washington
  • Understand and interpret regulatory guidance, contract language and payer specific policies
  • Make decisions with respect to his/her delegated responsibilities
  • Interpersonal skills necessary in order to communicate effectively with patients, patient’s families, physicians, and other health care providers to comprehend and disseminate technical information through good verbal and written skills when using the English language

Skills For Clinical Appeals Representative Resume

  • Demonstrate initiative and judgment in reviewing accounts, preparing correspondence, requesting payment and maintaining workflow
  • Perform audits on incoming denials, appeal documentation and report findings/training suggestions to Management
  • Utilize all available resources for optimum achievements, (i.e., Websites, Publications, payer and 21C managed care updates, coding policy updates/changes and apply these changes to the appeals & documentation process
  • Assign appeal letters to collector same day the clinician returns a letter
  • Follow up with clinicians on overdue appeal letters
  • Schedule peer to peer calls with payors and Air Methods Corp. Medical Directors or Flight Nurses
  • Schedule and attend medical necessity denial hearings

Skills For Collection Specialist Clinical Appeals Resume

  • Provide payment/denial feedback to the clinicians weekly
  • Resolve inquiries from the clinicians promptly. Escalate issues to leadership as appropriate
  • Coordinate all reviews of completed letters with Clinical Appeals Specialist. Send to Billing and Collection Specialists once approved. Note account based on policies and procedures
  • Indicate the percentage of time spent traveling: 0%
  • Identify trends in medical necessity denials and report to leadership

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