RN Clinical Appeals

RN Clinical Appeals

Job Description :

GENERAL OVERVIEW:

This job is responsible for all aspects of clinical appeal activities to include but not limited to, clinical record review, composing comprehensive appeal letters and compiling minimum necessary documentation to support services performed. Addresses and resolves potential and actual denials for assigned accounts as well as collaborates with AHN departments/Teams in denial prevention activities.

ESSENTIAL RESPONSIBILITIES

• Reviews clinical denials, audits and accounts as assigned. Composes and submits a comprehensive appeal letter based on clinical evidence within the medical record and evidence based literature. (40%)
• Submits appropriate clinical documentation while ensuring compliance with HIPAA regulations and confidentiality to support for the appeal. Follows account to resolution to include appropriate financial adjustment. (40%)
• Partners with other AHN departments to find resolution for payor and/or customer issues. (5%)
• Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies. (5%)
• Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies for improvement. (5%)
• Participate in denial reduction/prevention activities through denial root cause identification and trending as well as active participation in payor related calls and/or internal work groups. (5%)

Performs other duties as assigned or required.

QUALIFICATIONS:

Minimum

• High School/GED
• 3 years in Nursing
• RN License – PA
• Proficiency in Microsoft Office (Word, Excel, Outlook, etc.)
• Strong and effective verbal and written communication skills.

Preferred

• Bachelor’s Degree in Nursing
• 1 year in Utilization Management or Utilization Review
• 1 year in Case Management Experience
• 1 year with continuous documentation improvement
• 1 year Appeals Experience
• CPR
• Knowledge of CMS regulations and/or third party payer requirements for reimbursable care

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.