Clinical Appeals Nurse

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Analyzes payor denials and audits to identify potential revenue losses.

• Composes detailed and factual arguments for submission to third-party payers, medical review boards, or other relevant entities, applying clinical criteria to establish medical necessity.

• Acts as a liaison between the hospital and external third-party payors to challenge denied claims.

• Collaborates closely with the Physician advisor team to support appeals to payors.

• Tracks and reports payor trends to the management team.

• Drafts appeal letters to support procedures based on the payor's medical policy guidelines.

• Manages write-off accounts lacking sufficient medical necessity or documentation for the payor.

• Investigates and coordinates the completion of patient records necessary for retrospective precertification and insurance denial appeals.

• Engages with insurance companies and facilitates appeals through telephone or email communication.

• Organizes appeals requiring physician input for the payor and writes off claims with no further appeal options.

• Identifies potential revenue losses due to documentation issues or non-reimbursable processes through payors.

• Ensures that all appeals are submitted to the appropriate payor in compliance with appeal guidelines.

• Adheres to regulatory and accreditation requirements.

• Reviews claim documentation and retrieves supporting medical evidence from the system to validate the payor's medical policy guidelines.

• Searches for clinical evidence to bolster appeal arguments when existing resources are insufficient.

⛳️ Requirements

• Bachelor’s Degree in Nursing or a Specialized Diploma.

• A minimum of 10 years in clinical or case management/utilization review experience.

• Proficient in reading medical charts and identifying deficiencies in documentation.

• Ability to adapt to continuous changes within the health insurance sector for effective implementation of positive modifications.

• Knowledgeable in Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental processes.

• Familiarity with coding for claims payment.

• Understanding of insurance payors and their specific regulations.

• Experience with Epic workflow, including notes in account history and WQ workflows.

• Intermediate skills in Excel and MS Word.

• Must complete RCE Training and achieve a minimum score of 80% on the test.

• RN - Licensed Registered Nurse in the State of Pennsylvania.

🏝️ Benefits

• Medical (including prescription) insurance.

• Supplemental insurance.

• Dental insurance.

• Vision insurance.

• Life and AD&D insurance.

• Short- and long-term disability coverage.

• Flexible spending accounts.

• Retirement plans.

• Tuition assistance.

• Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.