XTN-4202166 | CLINICAL DENIALS AND APPEALS QUALITY AUDITOR

AGS Health, LLC (AGS) is a technology-enabled Revenue Cycle Management ("RCM") company that provides financial clearance, financial management, and clinical coding solutions and services to healthcare providers and vendors across the US. AGS Health has 10,200 employees across multiple offices in India and the US. The company generates annualized revenues of over $US 100 million. The CEO and the company have ambitions to transform from a traditional healthcare services company to an integrated technology and services organization that serves an expanded set of customer segments and offers a more diverse set of products and services.

The main responsibilities of a Clinical Denials and Appeals Quality Auditor include:

• Review inpatient and/or outpatient medical necessity and authorization denials to assess the validity of denials in a timely manner.
• Conduct comprehensive reviews of claim denials and accounts to determine necessary actions for reimbursement.
• Use payer policies, MCG, and InterQual criteria to evaluate if the account meets appeal criteria.
• Write appeal letters to payers, utilizing appropriate clinical indicators, Official Coding Guidelines, and relevant patient medical record documentation.
• Complete all necessary steps on specified accounts per Client’s SOPs, including documentation in the EMR and creation of appeal packages.
• Manage accounts until payment is received, written-off, transferred to patient-liability, or moved through other agreed-upon adjudication processes.
• Report quality results, track and trend educational opportunities for coding and CDI specialists, respond to client needs, and provide educational support and training.