Clinical Appeal Specialist II - RN (Remote)

Shared Services Center - Franklin, TN

Full-time - Mid Level

Remote - Franklin, TN

Executive, Legislative, and Other General Government Support

About the position

The Clinical Appeal Specialist II - RN is responsible for managing and filing medical necessity and level of care appeals, monitoring clinical appeal processes, and tracking clinical denials. This role requires a strong understanding of medical necessity criteria and the revenue cycle, as well as excellent communication and organizational skills. The position is remote and requires candidates to reside in specific states.

Responsibilities

• File medical necessity and level of care appeals using InterQual or MCG and CMS guidelines.
• Monitor clinical appeal processes for issues and trends and provide guidance and feedback to related departments.
• Track and manage clinical denials using current tools.
• Identify patterns and trends in denials and 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 coworkers.
• Provide education to staff as appropriate.
• Document all actions accordingly by documentation standards within Artiva, HMS, and other business office systems.
• Be familiar with policy and procedure manuals and other reference materials.
• Ensure confidentiality of all patient accounts by following HIPAA guidelines.

Requirements

• Must have diploma/degree from an accredited school of nursing.
• 5 years of clinical nursing experience.
• Current RN license to practice in state.
• 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.
• Ability to interact with all levels of hospital administration, physicians, and other healthcare team members.
• Ability to follow directions and perform work according to departmental standards.
• Ability to function effectively under stressful conditions.
• Excellent writing and communication skills.
• Effective organizational skills.

Nice-to-haves

• Utilization review and/or case management experience.