Clinical Appeals Nurse

Company Description

At EVERSANA, we are proud to be certified as a Great Place to Work across the globe. We’re fueled by our vision to create a healthier world. How? Our global team of more than 7,000 employees is committed to creating and delivering next-generation commercialization services to the life sciences industry. We are grounded in our cultural beliefs and serve more than 650 clients ranging from innovative biotech start-ups to established pharmaceutical companies. Our products, services and solutions help bring innovative therapies to market and support the patients who depend on them. Our jobs, skills and talents are unique, but together we make an impact every day. Join us!

Across our growing organization, we embrace diversity in backgrounds and experiences. Improving patient lives around the world is a priority, and we need people from all backgrounds and swaths of life to help build the future of the healthcare and the life sciences industry. We believe our people make all the difference in cultivating an inclusive culture that embraces our cultural beliefs.  We are deliberate and self-reflective about the kind of team and culture we are building. We look for team members that are not only strong in their own aptitudes but also who care deeply about EVERSANA, our people, clients and most importantly, the patients we serve.   We are EVERSANA.  

Job Description

THE POSITION:
The Clinical Appeals Nurse is responsible for managing medical denials by conducting a comprehensive review of clinical documentation to determine if medical necessity criteria are met. Where an appeal is warranted, the Clinical Appeals Nurse consults with healthcare providers, patients and the medical record to compose sound, compelling, factual arguments for submission. They manage the appeals process within prescribed timeframes in order to meet the operational goals of the department. Attendance at Administrative Law Judge Hearings may be required.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
Our employees are tasked with delivering excellent business results.  These results are achieved by:

• Successfully managing the appeals process from beginning to end within the designated timeframe
• Ensuring appropriate communication through the process with patient, insurance company and internal business partners
• Ensuring compliance with HIPAA regulations, to include confidentiality, as required
• All other duties as assigned

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.

EXPECTATIONS OF THE JOB:

• Determine why cases are denied and if an appeal is warranted using knowledge of payer requirements with medical chart data
• Utilize pre-existing criteria, clinical evidence and other resources as needed to develop sound and well-supported appeal arguments
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies
• Request additional information from providers, as appropriate, to facilitate timely appeals
• Gather and prepare case information for participation in Administrative Law hearings
• Summarize and present appeal outcomes to clients and participate in client meetings as needed
• Reviewing documentation related and level of care decisions with clients

The above list reflects the general details necessary to describe the expectations of the position and shall not be construed as the only expectations that may be assigned for the position.

An individual in this position must be able to successfully perform the expectations listed above.

Qualifications

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES:

The requirements listed below are representative of the experience, education, knowledge, skill and/or abilities required.

• Bachelor’s Degree in Nursing
• Current MO RN license in good standing
• 4 years’ experience as a clinical nurse in an acute care setting
• Knowledge of third-party payer regulations related to utilization and quality review
• Analytical, creative, and interpersonal skills essential
• Excellent communication (written, verbal, and presentation) skills
• Strong clinical and regulatory knowledge and skills as well as knowledge of payer requirements
• Strong organizational skills
• Demonstrated sense of urgency to drive to successful outcomes within the minimum required time frames

PREFERRED QUALIFICATIONS:

• 2 years’ experience in case management, discharge planning, and/or utilization review
• Experience with infusion and home health services as well as managed care
• Exper