Clinical Appeals Nurse - Remote

Overview

Job Summary
The Revenue Cycle Clinician for the Appellate Solution is responsible for recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review and for preparing and documenting appeals based on industry accepted criteria.

• Performs retrospective (post-discharge/post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Demonstrates proficiency in use of medical necessity criteria sets, currently Inter Qual® or other key factors or systems, evidenced by inter-rater reliability studies and QA audits. Constructs and documents a succinct, fact-based clinical case to support appeal utilizing the appropriate Inter Qual® module (Acute, Procedures, etc). If clinical review does not meet IQ criteria, uses other pertinent clinical facts to support the appeal.
  
  Pertinent facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process.
• Adheres to department standards for productivity and quality goals, ensuring accounts are worked in a timely manner based on payor guidelines.
• Demonstrates proficiency in utilization of electronic tools including ACE, nThrive, eCARE, Authorization log, Inter Qual®, VI, HPF, and Microsoft Office.
• Demonstrates basic patient accounting knowledge (UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc.).
• Additional responsibilities:
  • Serves as a resource to non-clinical personnel.
  • Provides CRC leadership with sound solutions related to process improvement.
  • Assists in development of policy and procedures as business needs dictate.
  • Assists Law Department with medical necessity reviews as capacity allows, up to and including attending mediation hearings or other litigation forums.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Demonstrates proficiency in the application of medical necessity criteria, currently Inter Qual®.
• Excellent written, verbal, and professional communication skills.
• Critical thinker, able to make decisions regarding medical necessity independently.
• Ability to interact professionally with clinical and non-clinical partners.
• Knowledge of managed care contracts including reimbursement matrices and terms.
• Ability to multi-task and conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
• Ability to conduct research regarding off-label use of medications.

• Must possess a valid nursing license (Registered).
• Minimum of 3 years acute care experience in a facility environment.
• Medical-surgical/critical care experience preferred.
• Appeals writing experience preferred.
• Minimum of 2 years UR/Case Management experience preferred.
• Managed care payor experience a plus in Utilization Review, Case Management, or Appeals.
• Previous classroom-led instruction on Inter Qual® or MCG products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred.

• Current, valid RN licensure.
• Certified Case Manager (CCM) or Certified in Utilization Review/Utilization Management/Healthcare Management (CPUR, CPUM, or CPHM) preferred.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to lift 15-20 lbs.
• Ability to travel approximately 10% of the time to facility sites, NIC sites, Headquarters or other designated sites.
• Ability to sit and work at a computer for prolonged periods, conducting medical necessity reviews.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Typical office environment requiring desk, chair, and office equipment such as computer, telephone, printer, etc.

• May require travel – approximately 10%.
• Interaction with facility Case Management and Physician Advisor is a requirement.

• Pay: $30.85 - $46.28 per hour. Compensation depends on location, qualifications, and experience.
• Position may be eligible for a signing bonus for qualified new hires, subject to employment status.
• Conifer observed holidays qualify for time and a half.

• Medical, dental, vision, disability, and life…