Appeals Nurse Resume Samples

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A Strosin

Agustina

Strosin

353 Kohler Crest

Chicago

+1 (555) 634 5483

353 Kohler Crest

Chicago

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

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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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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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