JOB SUMMARY: The Clinical Appeals Nurse is in responsible for creating a convincing and effective appeal based on clinical documentation, payer-specific standards, and compliance with federal and state policies. The Clinical Appeals Nurse is responsible for clinical denial appeals and follow-up, providing appropriate denial information to departments to ensure systems, processes, and effectiveness measures are created and implemented to resolve root cause issues and reduce/ eliminate denials. The Clinical Appeals Nurse ensures that appeals are filed on time.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Performs medical record reviews concurrently and/or retrospectively and be able to determine why cases are denied and whether an appeal is required
• Able to review clinical denials in a timely manner and appropriately utilizing clinical criteria sets such as of InterQual® criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medically necessary services denied for no authorization.
• Able to write an effective and efficient appeal based on clinical documentation and payer-specific policies and client-specific instructions.
• Able to think critically and able to use clinical judgment in providing effective and well-supported appeals.
• Maintains thorough and current knowledge in clinical expertise and stay relevant in the fast changing trends in healthcare, reimbursement methodologies and utilization.
• Able demonstrate basic patient accounting knowledge i.e. UB04 claim form and Explanation of Benefits (“EOB”) components, adjustments, credits, debits, balance due, patient liability, etc.
• Able to read and understand medical abstract information from handwritten to type written medical record.
• Demonstrates proficiency in utilization of electronic tools and competency in Microsoft Office.
• Able to observe specific payer guidelines for appeal submission and ensures compliance to law and regulations.
• Other tasks/functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirement of your position and our business.

MINIMUM REQUIRED QUALIFICATIONS (SKILLS, KNOWLEDGE AND ABILITIES

Education:

• Graduate of BS in Nursing
• Strong writing and grammatical skills
• Above average written and verbal communication skills

Certification/licensure

• Must be Registered Nurse and with active PHRN license.

Knowledge and Skills:

• Demonstrates proficiency in the application of medical necessity criteria.
• Ability to conduct intensive research regarding State/Federal guidelines and other regulatory processes.
• Excellent communication skills in verbal and professional letter writing skills.
• Able to think critically.
• MS Office proficient
• Ability to multi-task.
• Ability to work with minimal supervision and able to work under pressure within the given timeframe.

BENEFITS:

• Temporary Work From Home Setup
• Career Growth
• Annual Appraisal
• HMO Coverage on Day 1 plus 2 free dependents upon regularization