Job Description

• *Description**
• * _Summary:_**

Responsible for the management and communication of denialsappeals received from third party payers, managed care companies, andor government entitiesauditors related to medical necessity andor level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identifiedreferred for appeal based on Milliman Care Guidelines (MCG), InterQual, andor other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denialappeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denialsappeals will be reported to the facility.

• *_Responsibilities:_**
• Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services
• Review governmental contractors response letter in comparison to the medical records
• Communicates with facility regarding missing or insufficient medical documentation
• Review medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided
• Research issues using federal or law, federal regulations, and relevant CMS policies Communicates with members of the healthcare team identifying root causes for potential denials
• Communicates with the CMOVPMA regarding appeals and obtain signature for appeals
• Assures all discussions and appeals are filed timely
• Completes data entry in the Denial database for tracking, trends, and analysis
• *_Requirements:_**
• Associates Degree in Nursing
• RN License in state of employment or compact
• *_Work Type:_**

Full Time **EEO is the law - click below for more information:** < We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at (844) 257-6925.

Job Tags

Full time, For contractors,

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