Clinical Appeals Specialist II – RN (REMOTE)

• File medical necessity and level of care appeals using InterQual and CMS guidelines as needed.
• Monitor clinical appeal processes for issues and trends and provide guidance and feedback to related departments as needed.
• Track and manage clinical denials using current tools (manuals, training programs).
• Identify patterns and trends in denials; communicate to appropriate persons.
• Maintain documentation regarding all payor resources regarding denials and appeals processes.
• Understand and apply CHS 10-Step Appeal Process for denied claims.
• Know medical necessity criteria for outpatient testing and procedures.
• Follow and enforce accepted safety practices for patients and the hospital. Report safety hazards and initiate appropriate action. Participate in safety instructional programs.
• Observe excellent customer service skills when dealing with patients, families and/or significant others, outside vendors, coworkers, and physicians.
• Provide education to staff as appropriate.
• Document all actions accordingly by documentation standards within Artiva, HMS and other business office systems as required.
• Be familiar with policy and procedure manuals and other reference materials.
• Ensure confidentiality of all patient accounts by following HIPAA guidelines
• Perform additional duties as assigned or requested.
  
  

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge/Abilities

Required

   

• Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures.
• Understanding of the revenue cycle and the responsibility and goals of each area
• Must be able to interact with all levels of hospital administration, physicians and other healthcare team members they impact the revenue cycle
• Must be able to follow directions and perform work according to departmental standards and must be able to function effectively under stressful conditions.
• Excellent writing and communications skills as well as effective organizational skills a must.\
  
  

Reasoning Ability: Ability to define problems, collect data, validate data, establish facts, and draw valid conclusions

Required

Computer Skills:

   

• Microsoft office
  
  

Education/Experience

Required

   

• Must have diploma/degree from an accredited school of nursing
• 5 years of clinical nursing experience.
• Certificates and Licenses: Current RN license to practice in state
  
  

Preferred

   

• Utilization review and/or case management experience