Clinical Appeals RN Job Description
Clinical appeals RN
provides education and act as a resource to clinicians, supervisors, office staff, and billing staff with regards to OASIS C requirements, CMS guidelines, home care ICD-10 coding, PPS guidelines and billing related issues.
Clinical Appeals RN Duties & Responsibilities
To write an effective clinical appeals RN job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical appeals RN job description templates that you can modify and use.
Sample responsibilities for this position include:
Referring substantiated quality of care issues to the Quality Improvement and Credentialing Departments
Maintaining absolute file integrity with regards to content, location and confidentiality
Preparing for and participating in regulatory site visits
Assisting with training of new department employees
Ensuring that appeals and grievances are categorized and processed within New York State and Federal time frames
Entering all appeals and grievances in the Unit's software tracking system
Identifying potential quality issues and initiate investigations
Reviews, triages and prioritizes cases to meet turnaround times
Researches and analyzes complex issues
Develops and/or reviews documentation and correspondence reflecting determination
Clinical Appeals RN Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Clinical Appeals RN
List any licenses or certifications required by the position: MCG, CPC
Education for Clinical Appeals RN
Typically a job would require a certain level of education.
Employers hiring for the clinical appeals RN job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, School of Nursing, Graduate, Management, Health, Associates, Healthcare, Therapy, Education, Health Care
Skills for Clinical Appeals RN
Desired skills for clinical appeals RN include:
Milliman and CMS
MCG and CMS guidelines
DOL and state appeals guidelines
ICD - 10 / CPT coding
Regulatory and payer requirements for reimbursement and reason for denials by insurance plans
Experience with HMO and Managed Care
Medicaid / Medicare
CMS Regulations
Community
Experience with CPT and ICD-9 coding
Desired experience for clinical appeals RN includes:
Interacts with the member, provider and/or A&G staff to ensure resolution of plan recommendations
Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc)
Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs), eCARE, Authorization log, InterQual®, VI, HPF, competency in Microsoft Office
Demonstrates basic patient accounting knowledge UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability
Identify coding or clinical documentation issues and work to correct the errors in a timely
Provides introductory and ongoing training and education to Clinical Appeals staff to ensure that policies and procedures are followed
Clinical Appeals RN Examples
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Clinical Appeals RN Job Description
Job Description Example
Our company is growing rapidly and is looking for a clinical appeals RN. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical appeals RN
- Review of coding edits and reimbursement issues
- Supports hospital / medical staff to resolve claim issues, concurrently and retrospectively, with facilitation with insurance carriers, education to prevent denials through clinical and documentation process improvements, and producing trend and detail claim denial reports
- Review medical records using evidence based medical criteria
- Respond to members and/or providers in writing with the results of appeal review in accordance with Complaints and Grievances Department standards and all applicable regulatory requirements
- Review and approve Administrative appeals, including retro authorizations and requests that meet medical criteria
- Review first and second level appeals for medical necessity, completes a comprehensive medical necessity packet summarizing clinical facts for the Medical Director review
- Provide knowledge and expertise related to third party government and non~government payer clinical denials and appeals processes
- Analyze clinical denials and proactively gather the required clinical information and submit appropriate appeals to third party payers on a timely basis
- Coordinate collaboration and peer to peer appeals with the site Physician Advisors for designated appeals by managing the input and output reporting from the system audit tracker
- Provide updates and insight to reduce denials and improve revenue cycle performance to the Director and Manager of Denials and Underpayments, Director of Revenue Integrity and the SRCO Leadership Team
Qualifications for clinical appeals RN
- 2 years of Care Management and/or Utilization Management Experience
- Knowledge of third-party healthcare insurance plans, denials and appeal procedures
- Evaluates for medical necessity and appropriate levels of care
- Must have a minimum of three to five (3-5) years of active nursing experience
- Prior case management and clinical denials management experience
- Experience with McKesson (interQual) and/or Milliman Care Guidelines
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Clinical Appeals RN Job Description
Job Description Example
Our growing company is looking to fill the role of clinical appeals RN. 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 clinical appeals RN
- Educate others regarding guidelines (e.g., Milliman Care Guidelines, CMS), criteria, and procedures (e.g., cases that meet expedited review guidelines, training internal staff)
- Screen or respond to customer requests (e.g., expedited review, training requests, questions regarding rules/guidelines)
- Provide feedback/information to internal or external customers (e.g., trends, feedback on prevention of errors, communication of findings)
- Educates others around new or existing regulatory requirements
- Find answers to basic questions and determine what other information could provide a more complete understanding of the situation
- Eventually move into the Supervisor Roll
- Case Management Review
- Manage MTAC updates relevant to business that meet expedited review guidelines, training internal staff
- Review Complex Cases Transgender, BRCA
- Manage Quarterly QIMC
Qualifications for clinical appeals RN
- Professional Utilization Review (PUR)
- Knowledge of government reimbursement methodologies and denial issues
- Must have access to install secure high speed internet (minimum speed 1.5 download mps & 1 upload mps) via cable / DSL in home (wireless / cell phone provider, satellite, microwave, does NOT meet this requirement
- Interqual experience
- Minimum 3 years clinical experience as an RN including in an acute, inpatient hospital setting
- Active, unrestricted RN license in Tennessee
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Clinical Appeals RN Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of clinical appeals RN. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical appeals RN
- Contact appropriate parties (internal and/or external) as needed for additional information to properly formulate the clinical appeal
- Determine root cause of each denial and apply company-specific coding for trending and analysis
- Complete all required annual training
- Facilitate the local appeal process for medical and experimental denials
- Perform medical reviews/audits, analyze audit results and report findings to promote and improve processes
- Promote coordination of care and patient advocacy
- Be responsible for the achievement of consistent and/or expected clinical conditions
- Be responsible for efficient resource management
- Reviews and completes denial/appeal requests
- Stays current with Federal and State regulations regarding medical necessity for inpatient and observation hospitalizations
Qualifications for clinical appeals RN
- Tennessee residency required
- Minimum 3 years clinical experience as an RN including Behavioral Health experience
- Active, unrestricted RN license in the state of MA
- This position will require strong critical thinking, analytical and research skills along with the ability to adapt to change and work in a high volume environment
- Minimum one year case management experience required
- 2+ years’ experience in autoimmune, primary immune, and / or inflammatory disease states
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Clinical Appeals RN Job Description
Job Description Example
Our company is growing rapidly and is looking for a clinical appeals RN. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical appeals RN
- Responsible for utilization review duties in collaboration with Case Managers
- Completes audits for appropriate utilization of resources, develops/implements action plans when appropriate
- Advocates for payment of services, collaborates with physicians and the UM Committee
- Collects and analyses denial data for submission to Department Leadership and the Utilization Management Committee
- Completes requested audit for medical necessity, develop/implements action plans appropriately
- Conducts audits of potential high risk denial areas and implement action plans as appropriate
- Facilitates the completion of Case Management services and discharged medical record review as needed for medical necessity and appropriate patient status / service and plan of care
- Promotes the optimal allocation of health dollars through accurate, effective and timely appeals
- Uses evaluative and outcome data to improve ongoing care management services
- Review pre- service appeals for clinical eligibility for coverage as prescribed by the Plan benefits
Qualifications for clinical appeals RN
- 2 years of experience with interpreting plan language / Insurance Benefits
- Experience in Managing / Supervising a Team of non-clinical analyst
- Government payor knowledge, commercial payor knowledge and contract interpretation skills
- Three (3) years of experience in nursing required with prior experience in Utilization Review, Home Health, Quality Management and / or Discharge Planning
- Strong background in the use of system software for documentation
- Understanding of regulatory compliance in a healthcare setting
5
Clinical Appeals RN Job Description
Job Description Example
Our innovative and growing company is looking for a clinical appeals RN. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical appeals RN
- Provides introductory and ongoing training and education to Clinical Appeals staff to
- Processes appeals and grievances in accordance with internal company policy
- Enters data into appropriate medical management services
- Collaborates with other departments to thoroughly investigate appeal and grievances
- Handle clinical appeals from end to end
- Serves as a clinical resource and provides support and expertise to the appeals specialists
- Assist appeal specialist with determining the appropriate match specialty for each case and level, the match specialty medical reviews and questions for independent physician consultants
- Reviews the appeals specialist’s investigation documentation, member and provider contacts, and other significant information in the Member Appeals Systems
- Helps with the creation and updates to written correspondence with members and providers
- Reviews case summaries for Level 1 and Level 2 prior to committee meetings
Qualifications for clinical appeals RN
- Bachelors Degree in Nursing or a related field or Master’s degree in health care or business administration a plus
- Experience in hospital and/or intergrated healthcare system
- Texas Registered Nurse License Required
- Minimum two (2) years previous experience in managed care and denials management in a healthcare business office setting required, or minimum five (5) years previous experience in areas such as case management, utilization management, clinical pathways
- Extensive knowledge of healthcare third party reimbursement, variance and denial records
- Prior experience with Epic Hospital Billing Resolute Preferred