Clinical Appeals Specialist II - RN (REMOTE)
Essential Duties and Responsibilities: include the following. Other duties may be assigned. 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 Computer Skills: Required 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
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