Job Description

Location: Steward Health Care
Posted Date: 4/26/2022
The Appeal & Audit Coordinator will appeal all inpatient level of care denials through medical record review meeting the Medicare, Medicaid and private insurer contractual deadlines for denial reconsideration. The Appeal & Audit Coordinator will coordinate and appeal all external payer audits by performing chart review analysis and data collection for recovery strategies and payment accuracy. The Appeal and Audit coordinator is responsible to assist with outpatient appeals on an as needed basis.


  • Upon receipt of verbal and/or written denial notification for inpatient level of care denials, outpatient denials or audit findings, the appeal process will be implemented by analyzing and reviewing the medical record documentation
  • Generates an appeal letter to substantiate the medical necessity findings for the inpatient admission utilizing the Interqual ™ Criteria
  • Generates an appeal letter providing the supporting clinical documentation for the inpatient level of care denial, the outpatient level of care denial and audit denial findings
  • Is able to differentiate the difference between observation level of care and inpatient level of care admissions
  • Collaborates with HIM to obtain copy of patient's medical record as needed
  • Consults with case management and/or the attending physician regarding the case in review as needed
  • Submits an appeal packet to the denying insurer within the contractual appeal timeframes including all required supporting documentation
  • Submits a second level of appeal when applicable
  • Coordinates with the attending physician to obtain his/her letter of appeal for all MassPRO and other insurers if applicable
  • Develops, maintains, and manages cases utilizing an internal tracking system as appropriate (i.e. denial/appeal summary, outpatient denial summary and audit summary)
  • Identifies and monitors payer and/or operational issues on the monthly denial/appeal summary, outpatient denial summary and/or audit summary
  • Documents in BAR, Allscripts, Meditech, Revenue Recover and all supporting internal applications
  • Review account information in billing system (BAR) with the central billing office to verify payments are correct and take action as necessary
  • Participates in on-site audit process (including exit interview)
  • Review records as needed per internal guidelines prior to submission to payer for off-site audit
  • Communicates with the external auditor for clarification of audit findings as needed
  • Review insurer contracts giving input into potential issues that would pertain to inpatient denials, outpatient denials and audit findings
  • Consult with other disciplines and other ancillary departments (i.e. physician, coding, OR, cardiology, pharmacy, purchasing, case management, respiratory therapy, clinical documentation specialists, etc.) as needed to obtain necessary documentation to support clinical appeal
  • Coordinate submission of hospital's audit appeal response with other disciplines (i.e. patient accounts), as needed, within time limits identified by the audit report
  • Identify trends as a result of external audit findings and monitor audit activity on audit tracking tool
  • Working knowledge of the inpatient denial process, the outpatient denial process and audit process
  • Perform other duties as required


  • Knowledge of insurance state and federal regulations
  • Knowledge of the claims audit process
  • Outstanding leadership and interpersonal skills
  • Excellent written skills
  • Effective verbal communication
  • Computer knowledge including data entry, and use of an excel spread sheet


  1. Education: Bachelor of Science Degree or a licensed registered nurse with equivalent relevant experience.
  2. Experience (Type & Length): Five years’ experience in acute care setting; three to five years’ experience in managed care environment/benefits management; three to five years’ experience in Quality, Utilization Review, and/or Case Management.
  3. Certification/Licensure: RN license in good standing. Will consider LPN with 5 years acute care experience and knowledge of denial process, peer to peers and claims
  4. Other: Some travel to Steward facilities may be required.

Application Instructions

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