Inpatient Clinical Appeals Nurse

Imagine a career at one of the nation's most advanced health networks.

Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work.

LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary
Reviews inpatient account denials to determine if the case warrants an inpatient appeal and works closely with Physician advisor team to request in-depth review of written appeals if necessary. Functions as a resource liaison with external payors to appeal denied claims.

Job Duties

• Writes comprehensive, factual arguments to present to ALL payors, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity.
• Reviews inpatient payor denials to determine if an inpatient appeal is feasible.
• Functions as a resource liaison with external payors to appeal denied claims.
• Works closely with the physician advisor team to request in-depth review of written appeals if necessary.
• Monitors and reports payor trends to management team.
• Meets all measurable quality and productivity benchmarks as assigned by the management team.

Minimum Qualifications

• Bachelor’s Degree in Nursing or
• Specialized Diploma in Nursing
• 5 years composing clinical appeals or related experience
• 5 years experience with payor/contract relations
• Ability to read medical charts and identify deficiencies in documentation content.
• Ability to adapt to ongoing changes within the health insurance industry to effectively implement positive changes.
• Knowledge of medical policy criteria that supports inpatient admissions.
• Ability to work closely with utilization management, physician advisors, and any outside areas that would affect the inpatient appeals area.
• Knowledge of coding for payment of claims.
• Insurance knowledge of payors and their unique rules.
• EPIC EMR clinical documentation review and WQ routing rules.
• Intermediate excel and MS Word experience.
• Must complete RCE training and pass test with 80% or higher.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire

Preferred Qualifications

• Email comprehension and communication are critical components for this position.
• Ability to change processes due to payor adjustments.
• Ability to openly communicate with colleagues via Teams, phone, webex, etc.

Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.