Clinical Services

Struggling with denials and underpayments? Our clinical services team of nurses works with you to improve your cash flow and find lost revenue.

Our experienced clinical appeals nurse specialists review claims and medical records to resolve clinical disputes and audits, complete medical necessity reviews, defend services, submit supporting documents, follow up on payments, and more to recover denied reimbursement.

We’ll also be there to share our expertise and help you get to the root cause of your denials and underpayments—so you can better manage revenue going forward.

Our clinical revenue cycle nurses complete all types of Utilization Reviews for all payors, including status, level of care, medical necessity, pre-certification, concurrent review, and retro authorization. By focusing on the areas you need support most, we not only clear aging claims, we reduce downstream denials.

In other words, we’ll partner with your Utilization/Case Management and Revenue Cycle Teams to seamlessly reduce claims in holding, recover revenue, and more.

Typical challenges

Our clients typically face challenges recovering revenue from government and non-government payors in these areas:

Authorization:

  • Retrospective Medicaid authorization
  • Clinical precertification

Utilization/Case Management Medical Necessity Reviews:

  • Accounts in claims holding pending review
  • Medicare short stays
  • Concurrent review backlogs

Clinical Denials Management:

  • Clinical appeals
  • Clinical audit

Client Support:

  • General utilization management assessments
  • Focused assessments such as denials and appeals, or Recovery Audit readiness