Career Center
Clinical Appeals Nurse FT/40 HRS
CHRISTUS Health
Description Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or 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 identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or 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 denial/appeal 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 denials/appeals will be reported to the facility. Requirements EDUCATION: Graduate of an accredited School of Nursing with an Associate or Bachelor's degree (Preferred) in nursing. CERTIFICATION/LICENSES: Current RN Nursing license Interqual and/or MCG certification preferred. Case Management (CCM) or Managed Care certification preferred SKILLS:
EXPERIENCE: Two to four years of Case Management experience. Two to three years' experience in the denial and appeal process. Experience with managed care, governmental and/or RAC appeals strongly preferred. Computer experience in Microsoft Office (Word and Excel). NATURE OF SUPERVISION: -Responsible to: Director of Case Management ENVIRONMENT: -Bloodborne pathogen: A Works in a clean, well-lighted, ventilated smoke-free environment. PHYSICAL REQUIREMENTS: Vision acuity at least 20/40; hearing acuity at least conversational; color perception. Lift/Carry objects more than 40 lbs. per day.
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