Appeals Nurse Job Description

Appeals Nurse Job Description

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Appeals nurse provides leadership and oversight for all multidisciplinary patients ensuring optimum care is provided throughout their length of stay.

Appeals Nurse Duties & Responsibilities

To write an effective appeals nurse job description, begin by listing detailed duties, responsibilities and expectations. We have included appeals nurse job description templates that you can modify and use.

Sample responsibilities for this position include:

Assess patient's clinical need against established guidelines and/or standards
Evaluate the necessity, appropriateness and efficiency of medical services and procedures provided
Coordinate and assist in implementation of plan for members
Monitor and coordinate services rendered outside of the network
Advocate for the member/family among various sites to coordinate resource utilization and evaluation of services provided
Encourage member participation and compliance in the case/disease management program efforts
Document accurately and comprehensively based on the standards of practice and current organization policies
Interact and communicate with multidisciplinary teams either telephonically and/or in person
Understand fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes
Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review

Appeals Nurse Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Appeals Nurse

List any licenses or certifications required by the position: TCM, CPR

Education for Appeals Nurse

Typically a job would require a certain level of education.

Employers hiring for the appeals nurse job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Nursing, Education, School of Nursing, Associates, Graduate, Health Services, Science, Health Care, Health, Leadership

Skills for Appeals Nurse

Desired skills for appeals nurse include:

Individual judgment and experience to assess the appropriateness of service provided
Length of stay and level of care
Relevant and applicable Federal and State regulatory requirements and guidelines
CPT-4 and revenue coding and managed care case management is beneficial
Interqual Milimen & Roberts
Utilization review tools
Government reimbursement methodologies and denial issues
Computer systems
Networks and common software packages available to support database and spreadsheet applications
Operating systems

Desired experience for appeals nurse includes:

Current, active, unrestricted RN license to practice as a health professional within the scope of practice in the State of Tennessee and 2 years acute care clinical experience
Experience with the Grier Consent Decree and TennCare
Preparing and documenting appeal based on industry accepted criteria
Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums
Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required
Current active unrestricted RN license to practice as a health professional within the State of Tennessee required

Appeals Nurse Examples

1

Appeals Nurse Job Description

Job Description Example
Our growing company is looking for an appeals nurse. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for appeals nurse
  • Follow and enforce accepted safety practices for patients and the hospital
  • Conducting investigations and reviewing member and provider grievances and appeals
  • Reviewing prospective, concurrent or retrospective medical records of denied services for medical necessity
  • Extrapolating and summarizing essential medical information for Medical Director, consultants and other external review
  • Preparing recommendations to either uphold or deny appeal and forwarding to the Medical Director for approval
  • Ensuring that appeals and grievances are resolved timely to meet regulatory timeframes
  • Documenting and logging appeal / grievance information on relevant tracking systems and mainframe systems
  • Generating appropriate written correspondence to providers, members, and regulatory entities
  • Work with Medical Directors, VP of Quality and Care Management, Care Management team, A&G team, Claims and other cross functional teams
  • Represents QualChoice Health Plan Services in a courteous manner in attitude and appearance, behaving ethically and using a professional demeanor in oral and written communications with internal and external customers
Qualifications for appeals nurse
  • Requires complex critical thinking and the ability to be front facing to members via phone
  • Utilization Management and/or Case Management preferred
  • Demonstrated knowledge in the health field as acquired during three (3) years of nursing experience
  • Must have experience in Medicare Appeals, Grievance, Utilization Case Management or Compliance in Medicare Part C and Part D
  • Ability to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal
  • Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was denied
2

Appeals Nurse Job Description

Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of appeals nurse. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals nurse
  • May be responsible for creation and submission of appeal case files to external review entity with supporting justification of plan's decision to deny coverage
  • May perform review of external appeals cases prior to being forward to the Independent Review Entity (IRE) or reviews IRE cases as a gatekeeper
  • May be responsible for preparing Administrative Law Judge (ALJ) summaries and attending ALJ Hearings
  • Conducts investigations and reviews of member and provider appeals
  • Reviews retrospective medical records of denied services
  • May extrapolates and summarize medical information for medical director
  • Compose clinical appeal letters to send to payers for denial reconsiderations utilizing documentation, contract language, or voice recordings as applicable
  • Present a concise medical summary within each appeal based on support from the medical record
  • Demonstrate ability to interpret medical payer policy requirements
  • Strong ability to research evidence-based practices
Qualifications for appeals nurse
  • Identify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal
  • Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and research and provide a written detailed clinical summary for the Plan Medical Director
  • Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/response
  • Complete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process
  • Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators)
  • Adhere to department workflows, desktop procedures, and policies
3

Appeals Nurse Job Description

Job Description Example
Our growing company is searching for experienced candidates for the position of appeals nurse. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for appeals nurse
  • Demonstrate expertise in the application of the nursing process
  • Assess patients for care management services after a referral has been made based on the Admission screening and referrals for potential patient issues
  • Appropriately identify actual and potential care issues
  • Develop and manage a coordinated plan of care to meet patient and/or family needs
  • Monitor the patient/family progress towards achieving optimal functional status
  • Manage transition and business continuity of processes between the Payer Specialization Team, the SSCs and other stakeholders
  • Compose, edit, review, or otherwise support concise next-level appeal evaluations for disputed claims through review and assessment of clinical appeal letters, denial reconsideration documentation, payer denial documentation, medical records, other relevant documents
  • Assist in the authoring of complex contractual appeals and demand letters to insurance companies
  • Contact appropriate parties (internal and/or external) as needed for additional information to properly formulate and evaluate clinical appeals
  • Determine root cause of denials and apply company-specific coding for trends and analysis
Qualifications for appeals nurse
  • Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals
  • Read Medicare guidance documents report and summarize required changes to all levels department management and staff
  • Support the implementation of new process as needed
  • Active RN license, multiple state as required
  • Demonstrated experience in health plan Utilization Review, Discharge Planning, and Care Coordination preferred
  • Experience using Milliman Care Guidelines preferred
4

Appeals Nurse Job Description

Job Description Example
Our innovative and growing company is looking for an appeals nurse. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals nurse
  • Assist the Payer Specialization Team in denial avoidance and cash conversion strategies through the development of new and innovative methods and processes
  • Review and apply contract language as necessary to resolve denied claims
  • Utilize payer administrative manuals to dispute denied claims
  • Maintain and apply understanding of federal, state and local rules and regulations impacting denials and appeals
  • Combine strong relationship building skills and clinical knowledge to manage the Authorization and Appeals Management process
  • Responsible for investigating and processing appeal requests and authorizations
  • Primary duties include review of prospective, retrospective or concurrent medical records of denied services for medical necessity, processing authorizations
  • Serves as a liaison with marketing, business office and administration of the facilities
  • Coordinates the managed care determinations and distributes information to the marketing and admissions support staff across multiple markets
  • Identifies information needed from the referring hospital to finalize the authorization
Qualifications for appeals nurse
  • Ability to learn different systems & tools as necessary
  • Medical Coding experience/knowledge a plus
  • Prior experience working in Medicare Part C and D Appeals and Medicare Advantage preferred
  • Established track record of working under tight deadlines and managing stressful situations
  • Responsible for reviewing documentation of clinical appeals
  • Taking ownership of case from beginning to end with follow through
5

Appeals Nurse Job Description

Job Description Example
Our company is searching for experienced candidates for the position of appeals nurse. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for appeals nurse
  • Healthcare professional licensure required as Registered Nurse, LPN, Respiratory Therapist, Physical Therapist, Occupational Therapist or Social Worker
  • Three years healthcare experience
  • Proven history of effective relationship management in a matrix reporting structure
  • Review medical records and create Appeal letters to overturn a denial of service
  • Work with guarantors/insurance companies to secure payment on account balances outstanding for clinical reasons
  • Audit Medical Records to retrieve clinical information requested from payers, governmental agencies
  • Compose appeal letters
  • Review and process all correspondence including approvals and denials/adjustments, demand letters and results from various levels of appeals
  • Maintain knowledge of company policies and procedures as it relates to department job functions
  • Attend Team Meetings for internal process improvement and education as needed
Qualifications for appeals nurse
  • All letters to members must be at 6th grade level
  • Verifying all letters are correct and sent within time frame designated by health plan
  • Attend Health Plan meeting every Friday to review audit findings
  • Looking for 3-5 years of case management and utilization review experience
  • Candidate will participate in a weekly meetings
  • Candidate will be audited daily on quality

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