Job Description
- *Description**
- * _Summary:_**
Responsible for the management and communication of denialsappeals received
from third party payers, managed care companies, andor government
entitiesauditors related to medical necessity andor level of care. This
associate will be a liaison and point of contact for clinical denials and
appeal inquiries. The Clinical Appeals Nurse will review each case
identifiedreferred for appeal based on Milliman Care Guidelines (MCG),
InterQual, andor other relevant guidelines, determined the viability of the
appeal, and manage the appeal process. The Clinical Appeals Nurse is
responsible for appealing all inappropriate denials through all possible
levels of the appeal process. The RN Clinical Appeals Nurse will actively
manage, maintain and communicate denialappeal activity to appropriate
stakeholders, and report suspected or emerging trends related to payer
denials. Working with Case Management leadership, this individual will
orchestrate education and other performance improvement initiatives to impact
clinical quality, improve efficiency and mitigate lost revenue related to
medical necessity denials. Key Performance and trends related to
denialsappeals will be reported to the facility.
- *_Responsibilities:_**
- Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services
- Review governmental contractors response letter in comparison to the medical records
- Communicates with facility regarding missing or insufficient medical documentation
- Review medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided
- Research issues using federal or law, federal regulations, and relevant CMS policies Communicates with members of the healthcare team identifying root causes for potential denials
- Communicates with the CMOVPMA regarding appeals and obtain signature for appeals
- Assures all discussions and appeals are filed timely
- Completes data entry in the Denial database for tracking, trends, and analysis
- *_Requirements:_**
- Associates Degree in Nursing
- RN License in state of employment or compact
- *_Work Type:_**
Full Time
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Job Tags
Full time, For contractors,