Description

The Revenue Cycle Clinical Appeals Nurse is the liaison and point of contact for clinical denials and appeals that are received after claim submission. Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care.

Includes, but is not limited to the following:

• Use their clinical knowledge, experience, and advanced critical thinking to ensure accuracy and integrity of the full life cycle of medical necessity denial determinations is properly administered
• Evaluate clinical appeal letter correspondence for content, clarity, accuracy, and consistency
• Package & send appeal and grievance information to the payors, monitors for the outcome of appeal and takes action accordingly (notify the provider and member as per delegation agreement), track all appeal information
• Actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials
• Participate in the review of audit findings as needed

Minimum Qualifications:

• Ability to project a professional image
• Apply professional standards of practice in the work environment to both internal and external customers
• Knowledge of regulatory standards, compliance requirements, hospital policies and procedures, and third party requirements
• Familiar with medical terminology
• Strong understanding and working knowledge of Medicare and Commercial admission regulations
• Familiar with third-party admission and continued stay criteria
• Working knowledge of personal computer and software applications used in job functions (Word processing, graphics, databases, spreadsheets, etc.)

Education and/or Experience:

• A minimum of two years of Utilization Review/Case Management experience in either a managed care or hospital setting is required
• A minimum of two years’ experience in the denial and appeal process preferred

Certificates, Licenses, Registrations:

• RN license, in good standing and maintained current throughout employment
• CCM, preferred