Clinical Appeals Specialist II - RN (REMOTE) ID-9671

Job Description

Candidates must live within one of the following states to be eligible for this position; Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, Wyoming

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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

Clinical Appeals Specialist II - RN (REMOTE) ID-9671

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