Clinical Appeal Nurse - Remote $10K Sign on Bonus

JOB SUMMARY 

The Revenue Cycle Clinician for the Appellate Solution is responsible for:

a) Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review 

b) Preparing and documenting appeal based on industry accepted criteria.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• 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 use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process.
• Adheres to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines.  
• Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office.
• Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc.
• Additional responsibilities:
• Serves as a resource to non-clinical personnel.
• Provides CRC leadership with sound solutions related to process improvement
• Assist in development of policy and procedures as business needs dictate.
• Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• 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 interact intelligently and professionally with other clinical and non-clinical partners
• Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms
• Ability to multi-task
• 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.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment.  This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience required to perform the job.

• Must possess a valid nursing license Registered  Nurse
• Minimum of 3 years acute care experience with the last 2 years in a facility environment
• Medical-surgical/critical care experience preferred
• Minimum of 2 years UR/Case Management experience within the last 2 years preferred
• Managed care payor experience a plus either in Utilization Review, Case Management or Appeals
• Patient Accounting experience a plus
• Previous classroom led instruction on InterQual® or MCG roducts (Acute Adult, Peds, Outpatient and Behavioral Health) preferred

CERTIFICATES, LICENSES, REGISTRATIONS

• Current, valid RN licensure
• Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred

PHYSICAL DEMANDS 

The physical demands descri