Major Responsibilities:

Utilize clinical nursing expertise to assess denied claims to ensure timely evaluation and response and makes a determination whether or not the case is eligible for appeal by applying clinical and regulatory knowledge and using established clinical level of care criteria, documentation of medical necessity and appropriateness of status order. Utilize industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, and best practice standards, as well as a broad knowledge base and sound clinical judgment in reviewing medical records and writing appeals.Research and analyze denied claims using payor and government rule and regulations and makes a determination whether or not the case is eligible for clinical appeal by using third party requirementsConducts concurrent and retrospective clinical review based upon pre-established criteria approved by the Medical Staff for medical necessity appropriateness.Continues the appeal process until the case is overturned, appeal options are exhausted or decision is made to discontinue the process and is responsible for ongoing documentation of denial status in denial software.Prepares denials for clinical appeal processing in the case of authorization, coding, level of care and/or length of stay denials. Write appeal letters based on medical necessityPrioritizes appeals according to filing limitations established by the individual payor contracts and/or with governmental bodies. Secure needed medical documentation required or request by insurance carries to support the appeal process.Works to minimize third party payer denials. Identifies trends in claim denials and partners with various departments, including business office, pre-service, case management, utilizations management, contracting, audit, and physician advisors as deemed necessary, in an effort to provide education and/or corrective action to errors related to admission, charging, coding, documentation, patient status or billing.Provide support and clinical expertise to assist in resolving issues with third party payers during operational review meetings. Assist in documenting issues and trends that prevent payment of claims for service. 

Licensure:

Nurse, Registered (RN)

Education/Experience Required:

Bachelor's degree in Nursing

Knowledge, Skills & Abilities Required:

Experience with current CPT and HCPCS coding nomenclature and rules, ICD10 coding conventions and clinical documentation standards.Previous clinical/technical documentation and chart review experience along with understanding of medical terminology.Knowledge of appeals criteria and understanding of federal, state and local regulations.Experience with level of care criteria (MCG and/or InterQual) and clinical documentation standards.Excellent critical thinking and analytical skills, with a high attention to detail. Ability to meet deadlines while independently working in a fast-paced environment.Ability to take initiative and work collaboratively with others.Strong computer skills, including high proficiency with Microsoft Office Suite.Excellent writing skills necessary to facilitate the advanced appeal process

Physical Requirements and Working Conditions:

This position requires travel, therefore, will be exposed to weather and road conditions.Operates all equipment necessary to perform the job.Exposed to a normal office environment.