Authorization Denials Appeals Nurse

Shriners Children's

2d • Remote

About The Position

The Authorization Denials Appeals Nurse is responsible for managing authorization denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The appeals nurse will analyze pre- and post-service authorization denials to determine if there is clinical justification to submit a request for retro-authorization. The Authorization Denials Appeals Nurse will serve as a clinical resource to the Central Authorization Unit and provide peer-to-peer reviews when the payer allows a nurse to participate in the process. The Authorization Appeals Nurse will write sound, compelling factual arguments for appealing authorization denials. The person in this position will be responsible for maintaining a detailed knowledge of Third-Party Payers’ and Governmental Payers’ clinical/medical necessity/authorization criteria and will be responsible for filing compliant appeals in accordance with third-party and governmental contracts.

Requirements

• 3 years of clinical healthcare/hospital experience
• Third Party Payor Appeals/Revenue Cycle experience
• Working experience with Utilization Review activities and criteria sets used to determine eligibility for acute care hospitalization
• Functional knowledge of DRG and CPT coding systems
• Proficiency in MS Office
• Active RN License in current State of employment
• Associate's Degree

Nice To Haves

• Bachelor's Degree or BSN
• Experience with reviewing hospitals claims, denials and EOB's, appealing claims and working on claims in an audit

Responsibilities

• Screens denials for possible reconsideration, peer to peer, or formal appeal.
• Investigates denials and root causes and tracks and reports trends to remediate issues and assist with internal process improvement.
• Prepares and submits appeals per payer guidelines
• Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PFS and assists in the research and application of regulatory policies to support administrative appeals.
• Communicates pertinent clinical information to Physicians, Medical Directors, and other members of SCMG, as indicated, regarding evaluation of payer determinations.
• May educate other departments regarding payer changes and denial/appeal process.
• Understands clinically complex medical situations and communicates appropriately with insurers as needed.
• Utilizes working knowledge of basic coding guidelines for medical necessity and insurance authorization escalations and/or denials.
• Maintains expert knowledge of how to navigate payer websites to validate insurance eligibility and authorization requirements, as well as determine the method in which a payer requires appeal submission.
• This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned.

Benefits

• All employees are eligible for medical coverage on their first day!
• In addition, upon hire all employees are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service.
• Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected.
• Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more!
• Coverage is available to employees and their qualified dependents in accordance with the plans.
• Benefits may vary based on state law.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree