Position Summary: Responsible for coordinating the appeals process for third party payer denials, primarily RAC-related activities and commercial appeals beyond the first level, requiring complex clinical review and appeal letter writing. Responsible for collecting, analyzing, and reporting clinical risk factors for level of care discrepancies. Supports the overall quality, completeness of clinical documentation, and intensity of service application during the appeal process to ensure proper reimbursement is achieved.

 

Essential Functions and Responsibilities as Assigned:

Conducts patient medical record reviews and utilizes clinical knowledge to determine why cases are denied and whether an appeal is required. Confers with physician and management when needed, regarding appeal status. Writes appeal letters, when indicated, pertaining to RAC/3rd party payers’ disputes/overpayments. Appeal letters will include compelling factual argument and submit to insurance payer requesting timely payment for services. Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments. Prepares convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing reference and/or regulatory arguments. Prepares case feedback and provides for review. Communicates and collaborates with physicians, other team members, payers, and administrators regarding denial and appeals cases reviews and process. Maintains accurate complete documentation of all retrospective appeals and corresponding cases information. Enters and maintains data in case management software (i.e., Veracity, Optum, Cerner, etc.). Maintains a knowledge of the appeal processes, requirements of payers, and applicable CMS rules and billing regulations related to Medicare, Medicaid, and commercial insurance. Educates health team colleagues about complex clinical appeals, utilization review, including role, responsibilities tools, and methodologies. Ensures compliance with HIPAA regulations, to include confidentiality, as required. Performs other related duties as required and directed.

 

Qualifications:

Required

State licensure as a registered nurse (RN)Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position. Three years of recent case management, clinical documentation, or utilization review experienceFive years of clinical nurse experience in an acute care settingAmerican Case Management Certification (ACM) or obtain certification when eligible as defined by the Association Case Management Association, and maintenance of continuing education requirements

Preferred: 

Experience in utilization management/case management/clinical documentation.Certification in Case Management Certification (ACM or CCM)

 

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Additional Information Schedule: Full-time Requisition ID: 25005633 Daily Work Times: 8:00am-4:00pm Hours Per Pay Period: 80 On Call: No Weekends: No