RN Clinical Denials & Appeals

Job Description:

The Registered Nurse (RN) is a professional caregiver who assumes responsibility and accountability for assessing, planning, implementing and evaluating care of patients. The staff RN utilizes the nursing process by use of technology, therapeutic intervention, evidence-based practice and coordination of care with other health team members.

Practice Details:

This is a remote position

Monday – Friday for 8 hours to include the hours of 9:00 AM – 2:30 PM MTN

1. Uses nationally recognized evidence based utilization review criteria and reviews medical records to develop clinical appeal letters with supporting documentation. 2. Conducts reviews of patient accounts when requested by payers, audit firms, patient and RSC departments to determine the appropriateness of billed charges based on review of documentation in the medical record. 3. Determines the appropriateness of requests for patient class changes from the Care Management and RSC teams and changes the patient class as appropriate, in accordance with regulatory and payer policies. 4. Assesses the appropriateness of clinical appeal requests by using evidence based utilization review criteria, payer policies and Federal and State regulations. 5. Refers appeal cases to the designated Physician Advisor for obtaining support for appeals. 6. Collaborates with Care Management, Physician Advisors, Revenue Integrity, Compliance, legal counsel, and RSC teams to prepare appeals. 7. Identifies trends and opportunities for denial prevention and collaborates with the appropriate multidisciplinary teams to improve denial management, documentation, and appeals process. 8. Supports legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process. 9. Completes other projects and initiatives as assigned. This may include leading special projects, conducting meetings, conducting and analyzing regulatory research, performing audits and data analysis, and preparing documents or reports. 10. Promotes mission, vision, and values of SCL Health and abides by service behavior standards

Physical Requirements:

Ongoing need for employee to see and read information, labels, assess patient needs, operate monitors, identify equipment and supplies.- and -Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations.- and -Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, medication preparation, etc.- and -Expected to lift and utilize full range of movement to transfer patients. Will also bend to retrieve, lift, and carry supplies and equipment. Typically includes items of varying weights, up to and including heavy items.- and -Need to walk and assist with transporting/ambulating patients and obtaining and distributing supplies and equipment. This includes pushing/pulling gurneys and portable equipment, including heavy items. Often required to navigate crowded and busy rooms (full of equipment, power cords on the floor, etc).- and -May be expected to stand in a stationary position for an extended period of time.