Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Reviews payor denials and audits for potential lost revenue. Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. Functions as a hospital liaison with external third-party payors to appeal denied claims. Works closely with Physician advisor team to facilitate appeals to payors. Monitors and reports payor trends to management team.

This is not intended to be an exhaustive list of all essential functions or all duties performed. The essential functions listed below and percentage of time may vary between departments and locations, and are subject to change based on management discretion and organizational needs. Other responsibilities may be assigned at the discretion of management to meet organizational needs.

• Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor and the documentation found in the hospital/physician information system.
• Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor to meet their guidelines.
• Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials.
• Contacts insurance companies and conducts appeals via telephone or email.
• Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights.
• Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors.
• Ensures that all appeals are sent to the correct payor within the appeal guidelines.
• Ensures compliance with regulatory and accrediting requirements.
• Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor.
• Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

The requirements listed below are representative of the knowledge, skill, and/or ability required or preferred.

Education - Required

• Bachelor's Degree Nursing or Specialized Diploma

Experience - Required

• 10 years of clinical or case management/utilization review experience

Knowledge, Skills and Abilities - Required

• Ability to read medical charts and identify deficiencies in documentation content.
• Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
• Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
• Knowledge of coding for payment of claims.
• Insurance knowledge of payors and their unique rules.
• Epic workflow experience with notes in account history and WQ workflows.
• Intermediate Excel and MS Word experience.
• Must complete RCE Training and pass test with 80% or better.

Licenses and Certifications - Required

• RN - Licensed Registered Nurse_PA - State of Pennsylvania

Workday Day (United States of America)

Regular

Thomas Jefferson University

1101 Market, Philadelphia, Pennsylvania, United States of America