Appeals Nurse Coordinator

Position Summary

The Appeals Nurse Coordinator II will provide concurrent review and appeal support services for XSOLIS's growing client base. An Appeals Nurse Coordinator II will have experience with utilization management, DRG clinical validation, understand the state and federal regulations, have knowledge/experience with the denials and appeals process and have experience with physician documentation and electronic health records.

Essential Duties and Responsibilities

The essential functions include, but are not limited to the following:

Provide clinical reviews in accordance with Managed Care and CMS Regulatory Requirements in order to:

Assist with assigning appropriate level of care on a case-by-case basis

Determine if ICD-10 codes/DRG appropriately documented and meet clinical documentation integrity guidelines

Assist with the denial management process and construction of appeal correspondence

Determine if professionally recognized standards of quality care are met

Provide feedback to internal and external partners regarding level of care, length of stay, rationale on outcomes of cases, and clinical documentation for ICD-10s.

Apply clinical and industry guidelines, and use of in-depth knowledge that supports medically necessity of services rendered, and clinical documentation integrity of ICD-10s.

Identify opportunity to request additional, more complete, medical record documentation Review cases with screening criteria, such as InterQual, MCG or other appropriate platforms

Review cases with screening criteria (CDI), Pinson & Tang, ACDIS, along with familiarity with payer CDI guidelines.

Continually keep abreast of technology changes, regulatory issues, and medical practice through ongoing training and self-directed research

Provide client with a detailed Summary of Cases to track any discovery of trends or other pertinent information Research/Review contracts and speak to the payer on behalf of the client on why a claim decision was made

Ensures legal compliance by following guidelines, contracts, regulations, and the company's business plan

Minimum Qualifications (Knowledge, Skills, and Abilities)

Active RN or LPN license

3-5 years of clinical practice, with at least 2 of these years in auditing, appeals, medical review, and CDI. Case management or Utilization Review experience and CM, coding and/or CDI certification a plus.

Experience working with multiple instances of Electronic Medical Records (i.e. Meditech, Cerner, EPIC) Knowledge of the query process and utilization of CDI guidelines (Pinson & Tang, ACDIS, etc.)

Experience using case management guidelines (InterQual, Milliman, CMS 2MN Rule)

Excellent communication skills

CPT, ICD-10, and DRG coding

MS Office Suite - Specifically Word and Excel Organization and prioritization

Medical record technology Adobe DC/PDF

Note

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments.

All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others.

The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an "at will" relationship.