Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Job Description

Clinical Appeals Nurse - Full Time Remote - Jefferson Health

• Articulates the job's main responsibilities.
• 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.
• Captures and 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.
• Sets up and searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

Qualifications

• Required: Bachelor’s Degree Nursing or Specialized Diploma.
• Required: 10 years of clinical or case management/utilization review experience.
• Required: Ability to read medical charts and identify deficiencies in documentation content.
• Required: Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
• Required: Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
• Required: Knowledge of coding for payment of claims.
• Required: Insurance knowledge of payors and their unique rules.
• Required: Epic workflow experience with notes in account history and WQ workflows.
• Required: Intermediate Excel and MS Word experience.
• Required: Completes RCE Training and passes test with 80% or better.
• Required: RN - Licensed Registered Nurse.
• Required: PA - State of Pennsylvania.