Clinical Appeals RN Resume Samples
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Clinical Appeals RN Resume Samples
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BH
B Heller
Bobby
Heller
339 Caroline Trafficway
San Francisco
CA
+1 (555) 839 4549
339 Caroline Trafficway
San Francisco
CA
Phone
p
+1 (555) 839 4549
Experience
Experience
Phoenix, AZ
Clinical Appeals Rn-telecommute
Phoenix, AZ
Koelpin-Larkin
Phoenix, AZ
Clinical Appeals Rn-telecommute
- Working closely with a variety of internal departments
- Reviews Appeals and Provider Inquiries for clinical eligibility for coverage as prescribed by the Plan benefits
- Review provider post-service appeals for Medicare and Retirement
- Works within Department of Labor and State guidelines
- Review post service member and provider appeals
- Review post service provider appeals
- Works with less structured, more complex issues
New York, NY
Appeals & Grievance Clinical Spec RN Woodland Hills
New York, NY
Batz-Legros
New York, NY
Appeals & Grievance Clinical Spec RN Woodland Hills
- Interacts with the member, provider and/or A&G staff to ensure resolution of plan recommendations. Ensures communication of member or provider rights
- Performs other duties as assigned
- Prepares clinical summaries and assists HN Legal Department with litigation research
- Prepares questions on complex cases for consultant review or external third party medical review
- Collects, trends and monitors data; completes root cause analysis
- Prepares reports, data or other materials for committee presentation
- Recognizes potential quality care concerns
present
Houston, TX
RN Appeals & Grievance Clinical Specialist
Houston, TX
Sauer Group
present
Houston, TX
RN Appeals & Grievance Clinical Specialist
present
- Acts as member advocate addressing member or provider concerns
- Researches and analyzes complex issues. Acquires and reviews case against clinical records, clinical guidelines, policies, EOC/COI/Benefit Agreement, Benefit Policy and coding guidelines
- Provides input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
- Applies, interprets and communicates policies, procedures, clinical guidelines, medical policy, regulations and standards
- Develops and/or reviews documentation and correspondence reflecting determination. Ensures accuracy, completeness and conformance to standards
- Provides feedback on the effectiveness of policies and procedures
- Acts as liaison between the beneficiary, provider and HN to resolve issues
Education
Education
Undergraduate Degree
Undergraduate Degree
Drexel University
Undergraduate Degree
Skills
Skills
- Advanced ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate knowledge of community, state and federal laws and resources
- Intermediate proficiency in Microsoft Outlook, Word, Excel, and PowerPoint
- Intermediate proficiency in a healthcare management system
- Advanced knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Ability to use a proprietary healthcare management system
- Advanced ability to create, review and interpret treatment plans
- Supporting the management team on program initiatives
- 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
2 Clinical Appeals RN resume templates
Read our complete resume writing guides
1
Clinical Appeals RN 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
- 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 interpret clinical information, performing searches for relevant articles and assisting the customer through education and clear communication
- 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
- Supporting the management team on program initiatives
- Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by insurance plans
- 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
- Registered nurse possessing a current license issued by a state or jurisdiction within the United States, and unrestricted in any state
2
Senior Clinical Appeals RN Resume Examples & Samples
- Sorts, reviews and evaluates cases denied by all payers and determines follow through for first, second and third level appeals within contractual or appropriate timeframes
- Monitors inpatient denials and assists patients and physicians with management of the appeals process
- Writes first, second and third level insurance appeal letters
- Reviews and coordinates utilization issues concurrently and retrospectively related to denials from all payors
- Maintains data tracking systems and identifies Utilization trends
- Serves as a resource to all hospital staff related to Utilization Management issues
- Promotes staff development and education
- Assesses and monitors of quality issues, and follows-up with Quality Management
- May collaborate with multiple disciplines to identify utilization issues and determine admission appropriateness when accepting a transfer patient into facility
- Attends committee and staff meetings, as required
- Keep abreast of all changes in policies and procedures relating to Utilization Management and Case Management
- 1+ years Case Management Experience
- Hospital-based experience writing appeals to refute clinical denials
- 1+ years of clinical experience including, utilization management, discharge planning; third party payment systems; and appeals and denial processes
3
RN Appeals & Grievance Clinical Specialist Resume Examples & Samples
- Researches and analyzes complex issues. Acquires and reviews case against clinical records, clinical guidelines, policies, EOC/COI/Benefit Agreement, Benefit Policy and coding guidelines
- Summarizes cases including articulation of member's perception, initial denial determination and notification, analysis of medical records and application of all applicable policies, guidelines, benefit plans and laws, and rules and regulations
- Prepares questions on complex cases for consultant review or external third party medical review
- Presents cases to Medical Director and/or supervisor for review or determinations
- Collects, trends and monitors data; completes root cause analysis
- Acts as liaison between the beneficiary, provider and HN to resolve issues
- Prepares reports, data or other materials for committee presentation
- Applies, interprets and communicates policies, procedures, clinical guidelines, medical policy, regulations and standards
- Medical coding knowledge
- Able to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project
4
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Perform Pre-service utilization and concurrent reviews using Milliman criteria for Standard and Expedited Medicare member appeals in a fast-paced environment
- Discuss cases with treating physicians and other healthcare professionals to better understand plans-of-care which encompass In-patient care, DME, Radiology, Cardiology and Pharmaceuticals
- Gather all clinical information necessary to review and assess the appeal according to clinical criteria
- Unrestricted RN License in the state in which this role will be performed
- 5 years clinical nursing experience
- Flexibility to work a Tuesday thru Saturday, 8 hour shift OR a Wednesday thru Saturday, 10 hour shift
- Prior Utilization Management, Managed Care and or Appeals experience
- Prior Telecommute experience
5
Appeals & Grievance Clinical Spec RN Woodland Hills Resume Examples & Samples
- Conducts clinical review and evaluation of member and provider appeals and grievance using considerable clinical judgment, independent analysis and detailed knowledge of medical policies, clinical guidelines and benefit plans to determine the appropriateness of care provided including, but not limited to
- Acts as member advocate addressing member or provider concerns
- Interacts with the member, provider and/or A&G staff to ensure resolution of plan recommendations. Ensures communication of member or provider rights
- Prepares clinical summaries and assists HN Legal Department with litigation research
- Must have and maintain current, valid and unrestricted state RN license
- Experience in appeals and grievance casework
- Knowledge of risk management principles
6
RN Appeals & Grievance Clinical Specialist Resume Examples & Samples
- Active, valid, maintained & unrestricted state of CA Registered Nurse license required
- Three to five years of utilization management or quality management experience strongly preferred
- Experience using standardized clinical guidelines; InterQual experience preferred
7
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Works within Department of Labor and State guidelines
- Reviews and interprets Plan language appropriately
- Utilizes clinical guidelines and criteria appropriately
- Responsible for accurately documenting determinations
- 5+ years of clinical experience in an inpatient setting
- Basic level of experience with Microsoft Word and Excel, with the ability to navigate a Windows environment
- Demonstrated ability to work independently
- Above average written and verbal communication skills
- Knowledge of ICD-10 / CPT coding
- Milliman Care Guideline experience
- Knowledge of DOL and state appeals guidelines
8
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Review post service member and provider appeals
- Gather clinical information
- Perform reviews using applicable criteria
- Discuss cases with medical directors when applicable
- 2+ years of RN experience in an acute setting
- Ability to create, edit, save and send documents utilizing automated systems
- Ability to navigate a Windows environment, including Microsoft Word and Microsoft Outlook, as well as, to conduct Internet searches
- Undergraduate degree (BSN) or equivalent experience
- Claims and coding experience
- Utilization management, prior authorization, and case management experience
- Working knowledge of Milliman and CMS
9
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Perform pre-service utilization and concurrent reviews using Milliman criteria for Standard and Expedited Medicare member appeals in a fast-paced environment
- Discuss cases with treating physicians and other healthcare professionals to better understand plans-of-care which encompass inpatient care, DME, Radiology, Cardiology and Pharmaceuticals
- 3+ years acute care nursing experience
- Prior telecommute experience
10
Clinical Appeals Specialist Rn-work From Home Resume Examples & Samples
- 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
- At least three years of revenue cycle experience preferred
11
Senior Clinical Appeals Rn-telecommute Resume Examples & Samples
- Performs review of all claims denied for clinical related attributions, including but not limited to: level of care, no authorization, medical necessity, non-covered benefits and admission status
- Performs complete review of the medical record to include analysis of clinical documentation, case management documentation, application of criteria, and Physician Advisor input
- Coordinates/collaborates with relevant internal and external entities (Case Management, CBO, HIM, Revenue Services, MD office, CMS, Health Plan, etc...) during the analysis of a clinical denial
- Formulates and submits letters of appeal
- Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines, evidence based medicine, community and national medical management standards and protocols
- Documents in appropriate denial tracking tool (MIDAS +/Veracity, eFR)
- Participates in all government and non-government funded audit activity from appeal to legal proceedings (if needed) and maintains documentation of activity
- Collaborates with Physician Advisors in appropriately identified clinical denials requiring escalation or rebill
- Maintains clinical expertise and trends in healthcare, reimbursement methodologies and utilization management specialty areas by participating in professional organizations, seminars and educational programs
- Candidate needs to be able to work independently, maintain expected productivity while producing high quality product
- Active and unrestricted RN license
- 3+ years Clinical RN Experience
- Strong communication skills (verbal/written) and interpersonal skills
- Proficient in PC use, Microsoft applications (word, excel, PowerPoint) and working knowledge of hospital department computer systems
- Knowledge of insurance and Medicare billing practices
- Experience preparing appeals for clinical denials
- Experienced with Interqual and/or Milliman Guidelines criteria
- Knowledge of CMS Regulations
- Two years Utilization Review, Denial Management, Case Management, Clinical Documentation Improvement, Insurance background or related experience
- CDC or equivalent Coding Certification
- Certification in Clinical Documentation Improvement
12
Clinical Appeals RN Resume Examples & Samples
- Utilizes WellCare designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with appeal determinations
- Collects information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process. Reviews and interprets a variety of instructions and medical notes furnished in written and oral form to determine appropriate action towards appeal
- Applies regulatory requirements and accreditation standards to all review activity and reporting
- Applies accepted criteria to review process, utilizes the parameters and inputs review data into systems
- Prepares and submit projects, reports or assignments as needed to meet department initiatives and/or objectives
- Produces approval and/or denial letters on behalf of the Medical Director for submission to member, provider or hospital
- Ensures quality customer service, maintenance of confidentiality, and assistance in identifying process improvement opportunities related to appeals processing
- Ensures accurate data entry into the medical management system, including but not limited to appropriate procedure and diagnosis codes, approved abbreviations and relevant clinical information documented per departmental policies
- Performs special duties as assigned
- Required: 2+ years of experience in a clinical setting with general nursing exposure in utilization management (UM), to include pre-authorization, utilization review, concurrent review, discharge planning, case management with review, and/or skilled nursing facility reviews
- Preferred: 2+ years of experience in an acute care clinical setting (medical and/or behavioral health)
- Preferred: 2+ years of experience in managed care
- Advanced ability to create, review and interpret treatment plans
- Advanced ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Advanced knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Intermediate proficiency in Microsoft Outlook, Word, Excel, and PowerPoint
- Intermediate proficiency in a healthcare management system
- Ability to use a proprietary healthcare management system
13
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Review medical records and verify if the requested service meets criteria
- Review post service claims for clinical eligibility for coverage as prescribed by the Plan benefits
- Review and interpret Plan language
- Coordinate reviews with the Medical Director
- Utilize clinical guidelines and criteria
- Active, unrestricted RN license in state of residence -must be in a compact state
- Minimum 5 years clinical experience as an RN in an acute setting
- Strong proficiency with Microsoft Office products (Word, Outlook, Excel) and Internet applications
- Excellent communication, interpersonal, problem-solving and analytical skills
- Experience using MCG and / or Interqual
- Managed care and / or Medicaid experience
- Utilization management, preauthorization, concurrent review or appeals experience
- Medical coding experience / knowledge
14
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Clinical Appeals and Grievances (analyzing, reviewing appeals/grievances)
- Assesses and interprets customer needs and requirements
- Positions in this function include RN (with current licensure) roles responsible for providing clinical expertise in any of the following areas
- 3+ years clinical experience in a hospital, acute care, or direct care setting
- Medical record review/ appeal review experience
- Proficient level of experience with Microsoft Office Suite (Word, Excel & Outlook)
- Experience with MCG criteria, knowledge of Medicaid/Medicare, InterQual criteria experience preferred
15
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Reviewing cases within a regulatory timeframe Addressing urgent/emergency cases
- Addressing urgent/emergency cases
- Researching issues to mitigate risk
- Working closely with a variety of internal departments
- Communicate directly with members and physicians
- Minimum 1 year of clinical experience gained in an acute care or outpatient setting
- MS Office and Internet proficiency
- Strong communication skills, written and verbal
- Appeals experience strongly
- CPT and/or ICD 9 experience is strongly
- Managed care experience is strongly
- Utilization review and/or case management experience
16
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Reviewing cases within a regulatory timeframe Addressing urgent / emergency cases
- Addressing urgent / emergency cases
- CPT and / or ICD 9 experience is strongly
- Utilization review and / or case management experience
17
Senior Clinical Appeals RN Resume Examples & Samples
- 3+ years recent/current clinical experience in the acute care setting
- BSN degree
- Proficient in Microsoft office
18
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Active, unrestricted RN license in state of residence
- Minimum 5 years clinical experience as an RN in an acute, inpatient hospital setting
- Strong proficiency in Microsoft Office Word, Outlook, and Internet applications
- Experience using MCG and/or Interqual
- Utilization Management, pre-authorization, concurrent review or appeals experience
- Medical Coding experience/knowledge
19
Clinical Appeals Rn-telecommute From Anywhere Resume Examples & Samples
- Reviews Appeals and Provider Inquiries for clinical eligibility for coverage as prescribed by the Plan benefits
- Adherence to all confidentiality regulations and agreements
- Effectively and professionally communicates with both internal and external customers/providers, following prescribed policies
- Current RN Licensure in good standing in your state of residence
- Proficient computer and typing skills, Word, Outlook
- Health Insurance industry experience
- Knowledge of ICD - 10 / CPT coding
20
Clinical Appeals Rn-telecommute Resume Examples & Samples
- Review provider post-service appeals for Medicare and Retirement
- Gather clinical information including medical records and coverage criteria as it pertains to Medicare guidelines
- Ability to communicate and collaborate with other teams in order to gather medical information to process cases
- Communicate effectively in both verbal and written documentation
- Must meet quality and productivity metrics
- Ability to work independently and prioritize
- Attend mandatory trainings and scheduled staff meetings
- Engage in respectful and courteous team dialog via email, IM and in staff meetings
- Active, Unrestricted RN license
- Minimum of at least 2 years of RN experience in acute setting
- Working knowledge of MCG and CMS guidelines
- Proficient in Basic Computer Skills
- Ability to have high speed internet installed in home for Secure Job use only
- Designated HIPPA compliant home workspace
- Utilization management, prior authorization, case management or prior appeals experience
