Clinical Appeals Specialist

Clinical Appeals Specialist

The Clinical Appeals Specialist reports to the Manager Appeals. Under general supervision and within Brown University Health policies and procedures, works collaboratively with The Miriam Hospital and Rhode Island Hospital and multiple system-wide departments. Is responsible for review of medical records to ascertain appeal information and for the development of appeal correspondence. Analyzes clinical denials based on severity of illness and intensity of service using InterQual criteria and Center for Medicare and Medicaid Services (CMS) guidelines. Analyzes and reports data of audits at the facility and system-wide level. Provides education to Brown University Health staff and physicians to reduce future audit exposure. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate.

Responsibilities:

• Consistently applies the corporate values of respect, honesty and fairness and the constant pursuit of excellence in improving the health status of the people of the region through the provision of customer-friendly, geographically accessible and high-value services within the environment of a comprehensive integrated academic health system.
• Is responsible for knowing and acting in accordance with the principles of the Brown University Health Corporate Compliance Program and Code of Conduct.
• Is responsible for the hospitals appeals initiative by coordinating governmental and third party appeals with attending physicians and the medical director.
• Collaborates with government oversight agencies and third party payers regarding audits.
• Prepares, reviews, develops and maintains various manual and computerized documentation.
• Records and reports vital statistics on the denials and appeal data. Ensures completeness and accuracy.
• Prepares and presents high level professional presentations.
• Participates on various hospital, state and department committees to provide input for development of policies and procedures related to audits and appeals.
• Participates in ongoing, independent study, education-related professional activities and affiliations to maintain knowledge of government and commercial payer regulations and reimbursement issues.
• Researches and identifies opportunities for improvement and submits recommendations to manager and/or director.
• Conducts retrospective reviews and audits of hospital records to determine if level of care is appropriate and sufficiently documented.
• Works collaboratively at all levels of the organization.
• Participates in or leads various committees, task forces and quality improvement teams as needed.
• Performs other duties as assigned.

Work Locations/Expectations:

After orientation at the Corporate facilities, work is performed based on the following options approved by management and with adherence to a signed telecommuting work agreement and Patient Financial Services Remote Access Policy and Procedure. Full time schedule worked in office Full time schedule worked in a dedicated space in the home Part time schedule in office and in a dedicated space within the home Schedules must be approved in advance by management who will allow for flexibility that does not interfere with the ability to accomplish all job functions within the said schedule. Staff are required to participate in scheduled meetings and be available to management throughout their scheduled hours. Staff must be signed into Microsoft Teams during their entire shift and communicate with Supervisor as directed.

Minimum Qualifications:

• Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.
• Must have current licensure to practice as a Registered Nurse in the State of Rhode Island.
• Bachelor's Degree in Nursing, Health Science or Health Business required, Master's Degree preferred.
• Three years or more of relevant recent clinical and/or administrative experience in medical/surgical nursing; two years of which must be related to utilization review activities, demonstrating organizational skills and ability to make sound clinical judgment.
• Working knowledge of level of care criteria is required. Knowledge of state and federal regulations is desirable.

Work Environment and Physical Requirements:

Work is performed in general office environment, with some exposure to patient care areas when meeting with physicians, managers, etc. or to review other records not readily available.

Independent Action:

Performs independently within the department's policies and procedures. Refers specific complex problems to the supervisor when clarification of the departmental policies and procedures are required.

Supervisory Responsibility:

None.