Denial Review & Analysis
• Review payer denials (medical necessity, level of care, authorization, DRG downgrades)
• Analyze medical records against criteria such as MCG Guidelines and InterQual Criteria
• Identify root causes (e.g., missing documentation, auth issues, late UR submission)
Appeal Development
• Write strong, evidence-based appeal letters using clinical judgment
• Clearly articulate why inpatient/observation/services were appropriate
• Write appeal letters for No Auth denials using the reason for failure to obtain appropriate

authorization
• Reference payer policies, CMS and NJ State regulations, and evidence-based guidelines
• Prepare first-level, second-level, and external appeals
Physician Collaboration
• Partner with physician advisors for complex or high-dollar denials
• Assist with Peer-to-Peer preparation and support
• Translate clinical documentation...