Overview:
UCI Health is the clinical enterprise of the University of California, Irvine, and the only academic health system based in Orange County. UCI Health is comprised of its main campus, UCI Medical Center, a 459-bed, acute care hospital in in Orange, Calif., four hospitals and affiliated physicians of the UCI Health Community Network in Orange and Los Angeles counties and ambulatory care centers across the region. Listed among America’s Best Hospitals by U.S. News & World Report for 23 consecutive years, UCI Medical Center provides tertiary and quaternary care and is home to Orange County’s only National Cancer Institute-designated comprehensive cancer center, high-risk perinatal/neonatal program and American College of Surgeons-verified Level I adult and Level II pediatric trauma center, gold level 1 geriatric emergency department and regional burn center. UCI Health serves a region of nearly 4 million people in Orange County, western Riverside County and southeast Los Angeles County.
To learn more about UCI Health, visit www.ucihealth.org.
Responsibilities:

POSITION SUMMARY:

The incumbent is responsible to perform review of denied claims, conducting medical records reviews with use of standardized medical review software, determining claim appealability and initiates formal written or verbal appeals with various health plans. Must have knowledge of medical terminology, various health plan products (Medicare, Medi-Cal, HMO, PPO, Managed Care, etc.) private insurance and CMS guidelines. Previous experience substantiating appeals for Trauma, Acute and Psychiatric services. Also responsible for conducting external charge defense audits requested by insurance companies in collaborating with various audit firms for the conclusion of audits. Performs additional related duties, as assigned.
Qualifications:

REQUIRED QUALIFICATIONS:

• Three years’ experience working in clinical denial review and/or clinical appeal processing
• Three years of related clinical experience in an acute care setting
• Must possess the skill, knowledge and ability essential to the successful performance of assigned duties
• Must possess a current California RN license
• Must demonstrate customer service skills appropriate to the job
• Knowledge of Interqual
• Five years of internal and/or external audit experience
• Familiarity of audit software packages
• Excellent written and verbal communication skills in English
• Competent knowledge and experience with Microsoft Office computer applications, i.e. Word, Excel
• Ability to maintain a work pace appropriate to the workload
• Ability to establish and maintain effective working relationships across the Health System

PREFERRED QUALIFICATIONS:

• Knowledge of University and medical center organizations, policies, procedures and forms

• Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer