Appeals Nurse Resume Samples

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AS
A Strosin
Agustina
Strosin
353 Kohler Crest
Chicago
IL
+1 (555) 634 5483
353 Kohler Crest
Chicago
IL
Phone
p +1 (555) 634 5483
Experience Experience
Los Angeles, CA
Appeals Nurse
Los Angeles, CA
Abbott Inc
Los Angeles, CA
Appeals Nurse
  • Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review
  • Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs), eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office
  • Serves as a resource to non-clinical personnel.Provides CRC leadership with sound solutions related to process improvemen
  • Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc
  • Reviewing, researching and preparing 2nd level appeals functions utilizing clinical expertise
  • Reviewing clinical notes and other supporting documents from the patient medical record
  • Prepare feedback to clients and participate in client meetings
Detroit, MI
Remote Appeals Nurse
Detroit, MI
Walsh, Christiansen and Reinger
Detroit, MI
Remote Appeals Nurse
  • May interpret clinical information, performing searches for relevant articles and assisting the customer through education and clear communication
  • Tracking the status of outstanding appeals and trending appeals successes to help develop internal appeal strategies for specific payers
  • Supporting the management team on program initiatives
  • May work to minimize obstacles to coverage by using judgment to successfully plan next steps
  • May make case assessments and making informed, methodical decisions throughout a very complex process
  • Working off of a task list ensuring timelines and customer commitments are met
  • May utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted
present
Philadelphia, PA
Clinical Appeals Nurse
Philadelphia, PA
Torp-Wolff
present
Philadelphia, PA
Clinical Appeals Nurse
present
  • 2 Assists in the development of policies and procedures for all audit & denial appeals processes
  • 7 Assists with the orientation of new associates and provides for ongoing education, under the direction of the Director
  • Manage daily activities related to the CBO's Clinical Appeals function ensuring processes are performed efficiently and effectively
  • Provides guidance to ACS staff and physicians and their staff on clinical aspects of the appeals process
  • Analyze trends in insurance denials and work with insurance companies to implement ways to resolve underlying reasons for denials
  • Other responsibilities as directed by senior management
  • 0 Information Management/HIPAA
Education Education
Bachelor’s Degree in Nursing Required
Bachelor’s Degree in Nursing Required
Central Michigan University
Bachelor’s Degree in Nursing Required
Skills Skills
  • Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process
  • Ability to interact intelligently and professionally with other clinical and non-clinical partners
  • Possesses excellent written, verbal and professional letter writing skills
  • Strong attention to detail
  • Broad and deep knowledge of Medical policy, emerging technology and analysis of emerging evidence
  • Ability to conduct research regarding off-label use of medications
  • Great interpersonal skills
  • Excellent communication skills (written and verbal)
  • Knowledge of Utilization Management regulations
  • Demonstrates proficiency in the application of medical necessity criteria, currently InterQual
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8 Appeals Nurse resume templates

1

Clinical Appeals Nurse, Home Infusion Resume Examples & Samples

  • Receive patient history from patients, family members and physicians’ office
  • Provide assistance to the patient with obtaining facts and care history to substantiate appropriate infusion treatment
  • Document patient demographic data, synopsis of care history, and compose letters or e - mails to payers with proposed treatment plan in accordance with health plan requirements
  • Develop a consultant relationship with assigned physicians / clinics / patients to build and sustain a patient - focused approached to care
  • Examine work for exactness, neatness, and conformance to templates and company processes
  • Influence change across assigned payers
  • Facilitate resolution of treatment requests for assigned patients
  • Advocates patient viewpoints to payers on decisions directly affecting coverage - related concerns
  • Provide opportunities for patient involvement and input on care related issues and concerns to demonstrate commitment and responsiveness to patient needs
  • Participate on committees, work groups, and / or process improvement teams that improve patient outcomes and satisfaction
  • Reports statistical results of all efforts by presentations as needed at meetings of the management team
  • Licensed Registered Nurse (RN) in the state of Kansas, or have the ability to obtain licensure
  • 2+ years clinical experience as a Registered Nurse
  • Understanding of clinical documentation from physician offices and telephonic assessment notes of patients
  • Understanding of health insurance summary plan description language
  • Ability to clearly and effectively communicate ideas and data both verbally and in writing
  • Proficient in Windows - based operating software / system
  • Ability to work under pressure with tight deadlines
  • Ability to develop and maintain strong clinician / client relationships
  • Master’s Degree
  • Clinical experience with Neuro auto - immune diseases
  • Knowledge of specialty infusions such as IVIG and Remicade
  • Prior authorization, pre - certification, utilization review and / or appeals experience
  • Understanding of how payer reimbursements work, plus co - pays, co - insurances and deductibles
  • Understanding of government payment systems such as Medicare and Medicaid
2

Clinical Appeals Nurse Resume Examples & Samples

  • Demonstrates proficiency in the application of medical necessity criteria, currently InterQual®
  • Possesses excellent written, verbal and professional letter writing skills
  • Critical thinker, able to make decisions regarding medical necessity independently
  • Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process
  • Ability to conduct research regarding off-label use of medications
  • Must possess a valid nursing license (Registered or Practical/Vocational)
  • Minimum of 5 years recent acute care experience with the last 2 years in a facility environment
  • Managed care payor experience a plus either in Utilization Review, Case Management or Appeals
  • Previous classroom led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred
  • Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites
  • Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews
  • Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc
3

Clinical Appeals Nurse Resume Examples & Samples

  • 5 Compiles findings and schedules exit discussions, as required
  • 6 Notifies Director of Denials Management of all audit findings for final signature
  • At least 3 years of experience as a hospital-based nurse is required
  • At least 3 years of experience as a Case or Resource Manager is desired
  • Minimum 2 years acute care hospital inpatient coding and or charge auditing experience is preferred
  • Minimum 1 year experience with medical necessity appeals at all levels is preferred
4

Appeals Nurse Resume Examples & Samples

  • Demonstrates proficiency in the application of medical necessity criteria, currently InterQual
  • Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms
  • Must possess a valid nursing license (Registered or Practical/Vocational
  • Medical-surgical/critical care experience preferred
  • Minimum of 2 years UR/Case Management experience within the last 2 years
  • Patient Accounting experience a plus
  • Ability to lift 15-20lbs
5

Ssc-appeals Nurse Resume Examples & Samples

  • File medical necessity and level of care appeals using InterQual and CMS guidelines
  • 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
  • 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.Attend both mandatory and elective educational offerings to enhance professional performance
  • Provide education to staff as appropriate.Perform additional duties as assigned or requested
  • Understanding of the revenue cycle and the responsibility and goals of each area and how they impact the revenue cycle
6

Appeals Nurse Resume Examples & Samples

  • 2+ years of experience in a Managed Care Healthcare setting
  • Solid Appeals background
  • Broad and deep knowledge of Medical policy, emerging technology and analysis of emerging evidence
7

Clinical Appeals Nurse Resume Examples & Samples

  • Work as a liaison between Clinical Appeals and other departments to conduct billing and charging compliance in accordance with applicable Federal and State laws
  • Perform QA for Clinical Appeals function
  • Perform insurance defense audits as requested
  • Consistently demonstrates HIPAA compliance with regard to patients' protected health information
  • Provides clinical knowledge for CBO staff and consultation to management as needed
  • Manage daily activities related to the CBO's Clinical Appeals function ensuring processes are performed efficiently and effectively
  • Three to five years experience as an RN is required
  • UM experience required
  • Knowledge of inpatient admission criteria and medical necessity guidelines is required
  • CPC, CCS or other coding credentials preferred
  • Experience working in Patient Financial Services preferred with experience in the following areas: Insurance Defense Audits, Clinical Appeals denials analysis, RAC audits and Clinical Appeals Defense
  • Understanding the flow of the Revenue Cycle from beginning to end is preferred
8

Clinical Appeals Nurse Resume Examples & Samples

  • Communication - communicates clearly and concisely, verbally and in writing. This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately
  • Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
  • Interpersonal skills - able to work effectively with other employees, patients and external parties
  • PC skills - demonstrates proficiency in Microsoft Office applications and others as required
  • Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems
  • Technical skills - Professional presentation skills needed to represent facilities in legal issues
  • Basic skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
  • Clinical skills – ability to read and interpret medical records
  • Relevant education may substitute experience requirement
9

Clinical Appeals Nurse Resume Examples & Samples

  • Reviews appeals packet received from physician office to ensure that it contains all required components to complete appeal
  • Reviews appeals documents received and develops an appeal letter that includes all of the clinical parameters needed to provide insurer with an adequate and scientific rational for approval of prior authorization
  • Once appeals letter is complete, submits all documents to appropriate ACS staff member to be sent to payer in a timely fashion
  • Collaborates with ACS lay staff as needed to obtain required documents or information to facilitate completion of appeals letter
  • Collaborates with physicians and their staff as needed to obtain clinical information in order to complete appeals letter
  • Performs research as needed to obtain pertinent information for use in appeals documentation and to educate herself/himself on disease process
  • Uses only medically accepted or peer reviewed articles as supportive data for appeals letters
  • Maintains up to date documentation of all aspects of clinical oversight process in ACS patient data base
  • Provides guidance to ACS staff and physicians and their staff on clinical aspects of the appeals process
  • Maintains literature data base for ongoing use at ACS
  • Maintains state required nursing CEUS and seeks continuous learning opportunities
  • Practices with professionalism and accountability as an employee of ACS
  • Other responsibilities as directed by senior management
10

Clinical Appeals Nurse Resume Examples & Samples

  • 1 File medical necessity and level of care appeals using InterQual and CMS guidelines
  • 2 Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures
  • 3 Track and manage clinical denials using current tools (manuals, training programs)
  • 4 Identify patterns and trends in denials; communicate to appropriate persons
  • 5 Maintain documentation regarding all payor resources regarding denials and appeals processes
  • 6 Observe professional ethics in maintaining confidential information acquired concerning the personal, financial, medical or employment status of patients (and their families) provided services by the hospital
  • 7 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
  • Attend both mandatory and elective educational offerings to enhance professional performance
  • Provide education to staff as appropriate
  • Be familiar with policy and procedure manuals and other reference materials
  • 1 Demonstrates excellent technical and creative writing skills
  • 2 Assists in the development of policies and procedures for all audit & denial appeals processes
  • 3 Works with all members of the HMA audit & denial appeals team to support denial appeals generation whether completed at the hospital level, home office level, or externally by contracted companies
  • 4 Serves on various committees and task forces related to RAC and other payer audits when so directed by the Director
  • 5 Ensures that the Director is kept informed of important issues and problems
  • 6 In collaboration with the Director, must maintain current up-to-date knowledge of legislative, CMS, state Medicaid, other payers (including commercial and Medicare HMOs), and other governmental audit current trends in audits and denials
  • 7 Assists with the orientation of new associates and provides for ongoing education, under the direction of the Director
  • 2 Keeps manager informed of department based needs
  • 3 Understands cultural diversity and demonstrates an understanding of the value of all members of the healthcare team
  • 4 Ability to take action and get things done independently. Assumes responsibility promptly and effectively. Identifies the issue, develops steps and participates as needed to resolve the issue
  • 5 Demonstrates tact when dealing with patients, colleagues and the public
  • 6 Demonstrates ability to address issues and find a solution while at the same time achieving consensus with the individuals involved
  • 7 Adheres to the proper “chain of command” within the organization. (Rated either 5 or 1)
  • 0 Information Management/HIPAA
  • 1 Maintains confidentiality required in patient and peer relationships in the healthcare community as relevant to position
  • 2 Demonstrate knowledge of procedures for maintaining security, confidentiality and integrity of patient medical information
  • 3 Demonstrates skills and accuracy in collecting and inputting data into hospital computer system as relevant to position
  • 0 Equipment/Resources
  • 1 Demonstrates skill in use of equipment relevant to position, knowledge of appropriate safety procedures
  • 2 Diagnosis equipment problems, repairs or seeks out someone to repair
  • 3 Consistently inform appropriate person of problems encounter with repairs or calibration of equipment
11

Appeals Nurse Resume Examples & Samples

  • Communicates with medical office personnel to obtain pertinent clinical history and information. Documents and summarizes clinical or administrative rationale for all approvals and denials to all parties involved in the case
  • Implements quality assurance plans for specific contracts and coordinates this activity with the appropriate account managers or dedicated quality assurance staff
  • Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews
  • Participates in on-going training programs to ensure quality performance is in compliance with applicable standards and regulations
  • Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures
  • Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan's required timeframes
  • Documents communications with medical office staff and/or MD provider as required
  • Refers cases to appropriate internal reviewers according to the business needs of the particular health plan
  • Researches requests for post-determination review and categorizes each for processing based on the applicable health plan policies and procedures
  • Reviews and coordinates documentation; interprets data obtained from clinical records and ensures appropriate clinical criteria and policies are aligned with regulatory and accreditation requirements for members and providers
  • Tracks all post-determination cases to completion to ensure compliance
  • Trains new employees on the appeals and de-certification process as needed
  • Works closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals
12

Clinical Appeals Nurse, Payer Specialization Resume Examples & Samples

  • Bachelor Degree preferred
  • At least one year case management or similar appeal experience required
  • State RN or LPN License required (Active/Inactive)
13

Appeals Nurse Snf-remote Resume Examples & Samples

  • Collaborate with Manager, Clinical Quality for identified quality issues
  • Assist with project data analysis, reporting and feedback
  • Demonstrated proficiency in medical record analysis and ICD-9-CM and CPT coding methodology or commercial utilization review guidelines
  • Demonstrated experience with coding systems
  • Ability to apply healthcare data analysis to improve processes
  • Ability to be careful and thorough about detail
  • Ability to perform oral presentations
  • Active unrestricted RN license or RHIA, RHIT, RN, CCS, CPC or other licensed/accredited health care professional specific to scope of contract required
  • 3+ years clinical medical coding experience (1+ year clinical medical record auditing/validation experience required for coding only), preferably in a hospital setting
14

Audit Appeals Nurse Resume Examples & Samples

  • 5-7 years working with Chart Audits in a medical environment. General knowledge of ICD and CPT coding systems
  • Must possess strong analytical skills, good communications and organizational skills
  • Must have the ability to meet tight deadlines
  • Strong projects management skills
15

PRN Appeals Nurse Resume Examples & Samples

  • Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required
  • Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted
  • Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments, for an Administrative Law Judge hearing and participate in hearings by providing testimony, as necessary
  • Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable
  • Prepare feedback for Case Management departments at hospitals and participate in meetings if needed
  • Discuss documentation-related and level of care decisions with HIM and Case Management at hospitals and participate in meetings, if needed
  • Proficiently read and understand abstract information from handwritten patient medical records
  • Coordinate commerical/managed care audit requests as assigned
  • Ensure compliance with HIPAA regulations, to include confidentiality and integrity as required
  • Excellent interpersonal skills required to communicate with direct staff and internal/external customers
  • Must possess excellent time management and organizational skills
  • Demonstrated critical thinking, creativity, problem solving and decision-making skills
  • Must be able to handle multiple tasks simultaneously and concentrate in a busy environment
16

Grievance & Appeals Nurse Resume Examples & Samples

  • Investigate and resolve medical necessity appeals for all company products. Maintain documentation of cases
  • Respond to internal and external inquiries, assist with special member cases, and suggest resolutions via telephone or written communication
  • Identify potential quality of care issues within medical appeals; escalate as appropriate
  • Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary
  • Participate in departmental audits in preparation of regulatory site visits
  • Serve as a resource for less experienced or non-clinical members of the department
  • Bachelor’s degree in Nursing, or an equivalent combination of education and experience
  • Valid Rhode Island Registered Nurse license
  • Three to five years acute care clinical experience
  • Experience in a managed care environment
  • Knowledge of health insurance laws and regulations
  • Knowledge of utilization management appeals processes
  • Advanced analytical skills, with the ability to interpret and synthesize complex data sets
  • Knowledge of business process improvement techniques and strategies
  • Decision-making skills
17

Remote Appeals Nurse Resume Examples & Samples

  • Uses client approved clinical articles or if unavailable, may search for supporting clinical evidence to support appeal arguments when existing resources are unavailable
  • Receiving, documenting, investigating, and coordinating appeals
  • May interpret clinical information, performing searches for relevant articles and assisting the customer through education and clear communication
  • Tracking the status of outstanding appeals and trending appeals successes to help develop internal appeal strategies for specific payers
  • Working off of a task list ensuring timelines and customer commitments are met
  • May work to minimize obstacles to coverage by using judgment to successfully plan next steps
  • Supporting the management team on program initiatives
  • May perform tele-health duties as dictated by program needs
  • Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by insurance plans
  • Registered nurse possessing a current license issued by a state or jurisdiction within the United States, and unrestricted in any state
18

RN Appeals Nurse for the WNY Health Plan-teleworker Work Resume Examples & Samples

  • Experience working with the appeal process required
  • Experience working with the member complaints process required
  • This position requires time management skills, attention to detail, excellent organization skills and the ability to meet deadlines as outlined in our contract with the state
  • Computer literate: MS Office
  • Excellent written and verbal communication skills required
  • Must be able to work independently, ask questions and make decisions
19

Appeals Nurse Resume Examples & Samples

  • May utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted
  • Prepare feedback to clients and participate in client meetings
  • Understanding and interpreting payer guidelines and policies from a clinical perspective
  • May draft, submit and track action on appeals letters, reconsideration and re-determination requests and other communication with medical payers on behalf of providers and patients
  • May make case assessments and making informed, methodical decisions throughout a very complex process
  • Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting or medical insurance setting. In addition, having at least two to three years’ experience in case management, discharge planning, and/or utilization review is preferred
  • Experience at an insurance company in a clinical review capacity, or medical office experience with clinical review/PA experience, or direct appeals experience is preferred
  • Full understanding of the insurance claim submission / approval / denial / appeal process; previous direct experience in submitting appeals and advocating for appropriate clinical treatment of patients is highly desired
  • Neuro experience and/or movement disorder experience preferred but not required
20

Clinical Appeals Nurse Resume Examples & Samples

  • The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases in which a formal appeals request has been made or upon request by another Molina department to reduce the likelihood of a formal appeal being submitted
  • Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care
  • Applies appropriate criteria on PAR and Non-PAR (contracted and non-contracted) cases and with Marketplace EOCs (Evidence of Coverage)
  • Reviews medically appropriate clinical guidelines and other appropriate criteria with Chief Medical Officer on denial decisions
  • Resolves escalated complaints regarding Utilization Management and Long Term Services & Supports issues
  • Identifies and reports quality of care issues
  • Prepares and presents cases in conjunction with the Chief Medical Officer for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers
  • Represents Molina and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required
  • Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals
  • Provides training, leadership and mentoring for less experienced appeal LVN, RN and administrative staff
  • 3-5 years clinical nursing experience, with 1-3 years Managed Care Experience in the specific programs supported by the plan such as Utilization Review, Medical Claims Review, Long Term Service and Support, or other specific program experience as needed or equivalent experience (such as specialties in: surgical, Ob/Gyn, home health, pharmacy, etc.)
  • 5+ years Clinical Nursing experience, including hospital acute care/medical experience