Clinical Appeals Specialist II - RN (Remote)

Job Description

Essential Duties and Responsibilities: include the following. Other duties may be assigned.

• File medical necessity and level of care appeals using InterQual and CMS guidelines as needed.

• Monitor clinical appeal processes for issues and trends and provide guidance and feedback to related departments as needed.

• Track and manage clinical denials using current tools (manuals, training programs).

• Identify patterns and trends in denials; communicate to appropriate persons.

• Maintain documentation regarding all payor resources regarding denials and appeals processes.

• Understand and apply CHS 10-Step Appeal Process for denied claims.

• Know medical necessity criteria for outpatient testing and procedures.

• Follow and enforce accepted safety practices for patients and the hospital. Report safety hazards and initiate appropriate action. Participate in safety instructional programs.

• Observe excellent customer service skills when dealing with patients, families and/or significant others, outside vendors, coworkers, and physicians.

• Provide education to staff as appropriate.

• Document all actions accordingly by documentation standards within Artiva, HMS and other business office systems as required.

• Be familiar with policy and procedure manuals and other reference materials.

• Ensure confidentiality of all patient accounts by following HIPAA guidelines

• Perform additional duties as assigned or requested.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge/Abilities:

Required

• Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures.

• Understanding of the revenue cycle and the responsibility and goals of each area

• Must be able to interact with all levels of hospital administration, physicians and other healthcare team members they impact the revenue cycle

• Must be able to follow directions and perform work according to departmental standards and must be able to function effectively under stressful conditions.

• Excellent writing and communications skills as well as effective organizational skills a must.\

Reasoning Ability: Ability to define problems, collect data, validate data, establish facts, and draw valid conclusions

Computer Skills:

Required

• Microsoft office

Education/Experience:

Required

• Must have diploma/degree from an accredited school of nursing

• 5 years of clinical nursing experience.

• Certificates and Licenses: Current RN license to practice in state

Preferred

• Utilization review and/or case management experience