Job Summary: The Clinical Appeals Specialist is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Clinical Appeals Nursing Specialist will write sound, compelling factual arguments in order to recoup revenue. This position also facilitates collaboration between the Utilization Review Specialist's, Medical Staff, Physician Advisor, Nursing staff, Commercial Payers, VA, Managed Medicare Organizations, Medicare, and Medicaid (Center for Medicare/Medicaid Services) to ensure correct admission status as dictated by medical necessity criteria for correct reimbursement for level of care provided and to ensure that any denial is thoroughly reviewed and that an appeal letter, if warranted, is well written and submitted in a timely manner. In addition, the following are essential duties and responsibilities of the Nurse Reviewer: Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is warranted. Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted. Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments. Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Discuss documentation-related, level of care decisions, and clinical issues with physicians and other appropriate staff. Ensure compliance with HIPAA regulations, to include confidentiality, as required. Other duties as assigned. Works closely with the Utilization Review Specialists to ensure that concurrent medical necessity is achieved. Additionally, works with outside surgical offices when called upon, to provide Medicare Inpatient Only List knowledge to ensure that surgical procedures are correctly called in and billed appropriately.
Qualifications: Bachelor's degree from an accredited college with a strong clinical background, MSN preferred. Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required. Knowledge in areas such as InterQual Level of Care Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred. Must have excellent oral communication and organizational skills. Must have excellent writing skills. Previous experience with clinical resource utilization analysis, auditing, appeal writing, and chart review. Knowledge of state and federal regulations in regard to Medicare and Quality Management activities is a must. . Certification is required within one year of hire.
EOE AA M/F/Vet/Disability
