Clinical Appeals Nurse

Wilshire hires only the brightest and most experienced professionals in the healthcare revenue cycle management industry.  Wilshire will take the time to get know you and your employment history.  We will then place you in a role that will lead to a path of career success.  

About The Wilshire Group 

The Wilshire Group, a renowned boutique consulting firm in Los Angeles, specializes in revenue cycle optimization and fostering effective collaboration between operational and IT facets.  With a robust track record of aiding over 100 healthcare systems nationwide, our team thrives on professionalism, efficiency, and adaptability.

Our core values- professionalism, efficiency, and flexibility- underscore our commitment to creating an inclusive and dynamic workplace.  We embrace diverse narratives and believe in offering opportunities to exceptional individuals who bring their best to the table.

We are currently offering a contracted interim position at one of US News Best Hospitals 2022-23.  This position caters to top performers seeking a professional environment that acknowledges and values their dedication and proficiency.  While this role doesn’t offer benefits, it presents an opportunity to work within an organization that encourages talented individuals to surpass conventional boundaries.

Join us at The Wilshire Group, a place where talented professionals find a home to showcase their skills and contribute meaningfully to the healthcare landscape.

Why Wilshire? Employee Testimonial

“The number of RCM subject matter experts I get to work with each day is unreal.  Working alongside and as part of this team to help shape the RCM space is exciting.”-Patti Consolver, Director of Business Development 

This is a contracted position for 6+ months.  This position offers 65% of fee sharing.  Equivalent to $50-$70.00 per hour.  Applicants must be willing to submit a sample of their writing upon request.

Job Summary

Writes clinical appeals based on clinical audit/validation processes on denied accounts to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant, and accurate to support optimal reimbursement.

Responsibilities:

Interprets medical documentation to ensure the capture of all relevant coding.

Applies clinical and coding experience to conduct reviews of provider codes and billing specifically in DRG

Makes decisions of clinical appropriateness based on submitted provider information.

Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

Follows established guidelines/procedures.

Required Qualifications:

Active Registered Nurse (RN) license CPT coding experience or certification MS Office proficiency 18 months of medical record or coding auditing experience preferred

Strong knowledge of Epic systems 

Understanding of clinical assessment in MCG

Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information

Ability to work independently and manage workload

Excellent writing, editing, interpersonal, planning, teamwork, and communication skills

Experience applying CMS manual, NCCI edits, LCD / NCD documentation to audits

Required previous experience writing appeals with Medicare and MediCAL Advantage plans 

Strong knowledge of DRG reviews

Experience understanding the coding sequence rules and must have proficient knowledge of validating both diagnosis and procedure codes and clinical validation of diagnosis

This position consists of inpatient clinical validation payor reviews.  There are a few medical necessities for inpatient stay and coding however, these are not the most common denials worked.  

 

Wilshire is honored that you have taken the time to review/apply to our open position.  We will now take the time to review your experience and be in touch with you soon.