Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Jefferson Health Plans•Philadelphia, PA

7d•Remote

About The Position

This role involves reviewing payor denials and audits to identify potential lost revenue. The Clinical Appeals Nurse will write comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties, applying clinical criteria to establish medical necessity. This position functions as a hospital liaison with external third-party payers to appeal denied claims and works closely with the Physician Advisor team to facilitate appeals. The role also includes monitoring and reporting payor trends to the management team. The essential functions listed are not exhaustive and may vary between departments and locations, subject to change based on management discretion and organizational needs. Other responsibilities may be assigned at the discretion of management to meet organizational needs.

Requirements

Bachelor’s Degree Nursing or Specialized Diploma
10 years of clinical or case management/utilization review experience
Ability to read medical charts and identify deficiencies in documentation content.
Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
Knowledge of coding for payment of claims.
Insurance knowledge of payors and their unique rules.
Epic workflow experience with notes in account history and WQ workflows.
Intermediate Excel and MS Word experience.
Must complete RCE Training and pass test with 80% or better.
RN - Licensed Registered Nurse_PA - State of Pennsylvania

Responsibilities

Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor and the documentation found in the hospital/physician information system.
Facilitates write-off accounts that cannot provide adequate medical necessity or documentation for the payor to meet their guidelines.
Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials.
Contacts insurance companies and conducts appeals via telephone or email.
Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights.
Identifies areas for revenue loss due to documentation or processes not being reimbursable through payors.
Ensures that all appeals are sent to the correct payor within the appeal guidelines.
Ensures compliance with regulatory and accrediting requirements.
Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor.
Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

Benefits

medical (including prescription)
supplemental insurance
dental
vision
life and AD&D insurance
short- and long-term disability
flexible spending accounts
retirement plans
tuition assistance
voluntary benefits
tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service