Clinical Appeals LVN

TEKsystems•San Bernardino, CA

13d•$26 - $30•Onsite

About The Position

We are seeking a dedicated Clinical Appeals Nurse to join our Revenue Cycle Management team. The ideal candidate will be responsible for managing clinical denials related to medical necessity, level of care, and delays in service. This role involves reviewing medical records, preparing clinical documentation to support appeals, and following up on submitted appeals. The Clinical Appeals Specialist will work closely with a team of Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs) to ensure comprehensive and accurate appeal submissions. they are going to be looking at longer stay denials as far as inpatient because we do have a vendor that works our short stay admissions and denials. So, you know, like one to three day stays. So the ones that, the current position reviews is basically more than that. And so you may have, you know, longer stays that could be, you know, five days to like 100 days plus, yeah, and so, yeah, so which require a little bit more time because I have to sift through the medical records, you know, and try to, you know, come up with, the narrative and the, for the case and, you know, make sure that, you know, we have all the documentation to support it. medical necessity level of care, you know, DRG revisions, you know, delay in service, barren days, which is the same thing, you know, not meeting medical necessity for inpatient, once the follow up and the denial folks are following up on accounts and they determine that there's a clinical appeal denial, then they'll submit them to our team through the system. And so that goes into a work queue. And then I have two nurses. They're lvns and so, you know, that review them and see if we have enough clinical documentation to support an appeal. So they determine whether we're going to send one or we're going to accept it. So they do that review and then, you know, send the clinical appeal, and then we do have a follow up person that just does follow up.