Clinical Appeals and Disputes Nurse

University of Washington•Seattle, WA

2d•$102,000 - $144,000•Remote

About The Position

UW Medicine’s Patient Financial Services Department has an outstanding opportunity for a Clinical Appeals and Disputes Nurse. WORK SCHEDULE 100% FTE 100% Remote Days POSITION HIGHLIGHTS The Clinical Appeals and Disputes Nurse ensures that payers are prepared to reimburse the UW Medicine for services in accordance with the payer-provider contract, and works diligently toward the identification, mitigation, and prevention of clinical denials. This staff member uses their clinical expertise while reviewing initial clinical denials to determine next steps. Additionally, they conduct appeals as appropriate by reviewing medical necessity, and/or reconciling coverage-related issues. DEPARTMENT DESCRIPTION UW Medicine Patient Financial Services is a shared services department. UW Medicine includes UW Medical Center (UWMC) one of the nation's premier educational and research institutions and Harborview Medical Center (HMC), the only Level I trauma center in the entire WWAMI/five-state region. Patient Financial Services is responsible for the patient accounting functions for UWMC and HMC, including billing for inpatient and outpatient services provided at the Medical Centers.

Requirements

Active licensure to practice as a Registered Nurse in Washington State
Bachelor’s degree in Nursing
Certification in at least one of the following: certified healthcare chart auditor, certified professional in utilization review (or utilization management or healthcare management), certified case manager, certified documentation specialist, certified coder, certified professional medical auditor
Previous experience working as an RN
Extensive knowledge of ICD-10-PCS, ICD-10-CM, CPT and HCPCS coding principles and guidelines
Comprehensive knowledge of federal and state regulations related to documentation, coding and billing
At least three years of experience required in one of the following areas: clinical, case management, denials, billing
Familiarity with National Coverage Determinations and Local Coverage Determinations
Proficient in medical terminology and able to interpret patient medical records
Knowledge of medical necessity screening criteria (e.g., Milliman, InterQual)

Responsibilities

Document all payer communications thoroughly, and communicated payer decisions in a timely manner
Review clinical denials and initiate appeals process
Conduct medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals
Help present appeals arguments to Administrative Law Judge
Monitor and follow up on appeals throughout entire process, determine next steps to ensure appeals either result in an overturned denial or have proceeded as far as possible
Identify gaps in clinical documentation and work with clinical staff to develop and implement quality improvement and staff education initiatives
Assess the quality of charge capture and coding as they relate to clinical denials; assist revenue cycle leadership in improving processes
Analyze initial and fatal denial data to identify trends; share findings with revenue cycle leadership to drive process improvements
Review payer updates and communicate changes impacting revenue cycle