Clinical Appeals Nurse

Day (United States of America)

Clinical Appeals NurseThe Clinical Appeals Nurse will play an active role in the Revenue Cycle by successfully performing the tracking, resolution, and collection of Clinical Denials and Appeals. The Clinical Appeals Nurse will accurately document into the host system and QMS and supply the Manager of Case Management with accurate work stats. This person will also actively participate in Quality Improvement and process flows.- Active Florida RN license, or bachelor degree in related health field or equivalent experience.
- Prefer 3-5 years of Case Management, Utilization Review, or hospital business experience in the area of reimbursement methodologies.
- Must possess analytical skills.
- Prefer some experience in dealing with insurance carriers on disputes and settlement of claims.
- Must have knowledge of :
- EQ Health/Medicaid rules and regulations;
- FMQAI, PEPP;
- Cobra and Emtala rules and regulations;
- InterQual and Millimen Criteria for utilization review.
- Must have an understanding of the billing and collection process as related to healthcare claims.
- Must be able to deal effectively with the public and physicians.
- Must formulate comprehensive letters and account notes.
- Must have good PC knowledge and skills.
- Must be able to work successfully in a "team-work" environment.
- Identify clinical denials via fax, correspondence, system worklists, email, hard copy remittance advice and any other data source.
- Record clinical denials in the denial tracking database.
- Request all materials needed to submit a timely appeal.
- Send the appeal in accordance with specific payor guidelines.
- Record clinical appeals in the denial tracking database.
- Run follow up reports for aggressive follow up, as per policy.
- Record final outcomes in the denial tracking database.
- Participate in quality improvement for various stages of the Revenue Cycle.
- Provide clinical denial statistics to Manager, Case Management and Administration as needed.
- Provide clinical expertise and decision making to non clinical staff as needed.
- Able to analyze and monitor financial data reports.