GENERAL SUMMARY:
Responsible for completing retrospective clinical appeals for full or partially denied claims for Managed Care, Government, Non-Government and Commercial payors when the third-party payors do not meet the expected payment as modeled. The Clinical Appeals Nurse will write comprehensive, factual arguments to present to third party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. This position reports to the Manager, Denials.
ESSENTIAL DUTIES:
- Understands the revenue cycle and the responsibility and goals of each area and how their role impacts the system.
- Analyzes clinical denial/audit review patient medical records, utilizing clinical and regulatory guidelines, and applying knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
- Utilizes established clinical criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments.
- Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
- Collaborates with Case Management, HIM and/or other team members to determine appropriate responses when necessary.
- Contacts insurance companies to conduct telephonic or electronic appeals, if applicable.
- Elevates appeals to the appropriate manager/committee when necessary.
- Provides relevant feedback to applicable departments, related to denial root cause analysis and denial prevention.
- Ensures compliance with HIPAA regulations, to include confidentiality and integrity as required.
- Identifies and refers cases appropriately for Case Management, Quality Improvement for education and process improvement.
- Understands and applies payer specific appeal guidelines and elevates cases for payer peer to peer reviews.
- Participates in all educational activities, and demonstrates personal responsibility for job performance.
- Maintains a professional image and provides excellent customer service.
- Attends department meetings and education sessions.
- Meets/exceeds performance expectations within required timeframes.
- Practices and adheres to the "Code of Conduct" philosophy, Mission, and Values statement.
- Adheres to all Beaumont Health Policies and Procedures.
- Performs other duties as assigned.
STANDARD QUALIFICATIONS
A. Education / Training:
Bachelors in Science required
Associates or Bachelor's degree in Nursing preferred
B. Work Experience:
Minimum of two (2) years related experience in health care.
Background in Case Management preferred.
Must be familiar with revenue cycle structure and process.
C. Certification, Licensure, Registration:
LPN or RN
D. Other Qualifications:
Must be detail oriented and must possess excellent time management and organizational skills.
Strong verbal and written communication skills.
Proficiency in Excel, Word, PowerPoint and Access is necessary
Requires critical thinking skills, problem solving, decisive judgment, ability to work with minimal supervision and must possess excellent time management and organizational skills. Must be able to work in a stressful environment and take appropriate action.
PC skills- demonstrated proficiency in Microsoft Office applications and others as requires.
Policies and Procedures- demonstrates knowledge and understanding of organizational policies, procedures and systems.
Basic skills- able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately.
Technology skills- requires knowledge of computer systems, operating systems, networks and common software packages available to support database and spreadsheet applications. General knowledge of relevant system support and troubleshooting.
