Clinical Appeals Nurse
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Job Description
Clinical Appeals Nurse reviewing payor appeals and coordinating claim processes for Jefferson Health. Acting as a liaison with external payors to ensure compliance and documentation standards.
Responsibilities:
- Reviews payor denials and audits for potential lost revenue
- Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity
- Functions as a hospital liaison with external third-party payors to appeal denied claims
- Works closely with Physician advisor team to facilitate appeals to payors
- Monitors and reports payor trends to management team
- Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor
- Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor
- Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials
- Contacts insurance companies and conducts appeals via telephone or email
- Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights
- Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors
- Ensures that all appeals are sent to the correct payor within the appeal guidelines
- Ensures compliance with regulatory and accrediting requirements
- Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor
- Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable
Requirements:
- Bachelor’s Degree Nursing or Specialized Diploma
- 10 years of clinical or case management/utilization review experience
- Ability to read medical charts and identify deficiencies in documentation content
- Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes
- Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures
- Knowledge of coding for payment of claims
- Insurance knowledge of payors and their unique rules
- Epic workflow experience with notes in account history and WQ workflows
- Intermediate Excel and MS Word experience
- Must complete RCE Training and pass test with 80% or better
- RN - Licensed Registered Nurse_PA - State of Pennsylvania
Benefits:
- medical (including prescription) insurance
- supplemental insurance
- dental insurance
- vision insurance
- life and AD&D insurance
- short- and long-term disability
- flexible spending accounts
- retirement plans
- tuition assistance
- tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service
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