McLaren Health Care · 1 month ago
Appeals Audit Specialist
Mount Pleasant, MI
Full-time
Onsite
Mid, Senior Level
5+ years expMcLaren Health Care is responsible for timely and accurate processing of audits and denial activities from payers. The Appeals Audit Specialist will support internal and external customers in denial and appeals activities, monitor and audit processes, and collaborate with various departments for issue resolution and process improvement.
Health CareHospitalMedicalOncologyRehabilitation
Responsibilities
Supports activities consistent with Integrated Care Management Denials across all MHC subsidiaries
Accountable for achieving care management outcomes and fulfills the obligation and responsibilities of the role to support the clinical team
Collaborates with the Denials Appeals RN to ensure payer appeal/filing deadlines are met and achieve optimal payment for services rendered
Ability to write appeals demonstrating accuracy/proficiency in referencing support from the medical record documentation and coding guidelines with timely and successful submissions
Assists in identifying denial trends and selecting the most appropriate method for resolution
Provides support in response, tracking and completion of all payer audit/denial/appeal activity to ensure that timelines in the process are met, including requests for medical record documentation and the filing of responses and appeals
Appropriately documents denial/appeal activities; oversees and documents payer and third-party payer contractors (including federal and state payer) activities
Monitors and suggests modifications to workflows to maintain effective, timely and efficient processes
Assists with reconciliation process to verify accuracy and completeness of payers’ take-backs and rebilling based upon denial/appeal findings and maintains documentation of such activity
Provides recommendations for improvements, based on denial/appeal results and assist in implementing action plans. Assists subsidiaries with tracking, reporting, and developing action plans, as necessary
Assists in performance of follow-up reviews to assess adequacy of implemented action plans
Logs, tracks, refers and closes appeals timely
Participates in the revenue cycle process (Central Business Services – CBS) to ensure both compliance and the maximization of appropriate reimbursement on denied/appealed cases based on medical record documentation and coding guidelines
Participates on assigned designated corporate and subsidiary committees, to evaluate denial/appeal outcomes improvement
Attends continuing education sessions to maintain competency and knowledge of regulations in denials, utilization management, care management, clinical documentation, and leadership skills and participates in ongoing leadership training offered by ACMA
Performs other related duties as required and directed
Qualification
Required
Registered Health Information Technician (RHIT), Licensed Practical Nurse (LPN), hospital biller, or associate degree
5 years' health care experience
Preferred
Bachelor's degree in healthcare related field
ACMA or ACDIS memberships
Certified Medical Coder, Certified in Healthcare Compliance, Certified Coding Specialist, or Certified Clinical Documentation Specialist certifications
Company
McLaren Health Care
McLaren Health Care is a fully integrated health network committed to quality evidence-based patient care and cost efficiency.
10001+ employees
Funding
Current Stage
Late StageTotal Funding
unknown2021-01-01Acquired
Leadership Team
Chris Candela
President and Chief Executive Officer McLaren Flint
Chad Grant
Executive Vice President & Chief Operating Officer
Recent News
2025-11-10
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