RN _ Clinical Appeals - FT (11386)

CULLMAN REGIONAL•Cullman, AL

7d•Onsite

About The Position

· Serves as the liaison with government and commercial payers to resolved complex claims, ensure favorable reimbursement, and address other billing or payment issues. · Ability to write articulate and concise appeals by applying clinical knowledge, coding expertise and medical necessity. · Ability to detect trends resulting in denials and constructively report on the root cause to assist in resolution and prevention. · Responsible for evaluating likelihood of receiving a favorable resolution of medical necessity denials, payment discrepancies and contract misinterpretations. · Responsible for clearly documenting actions taken in each patient account. · Collaborates with physicians and interdisciplinary team as appropriate. · Complies with the various payer rules regarding the appeal/denials process. · Communicates with the patient access and billing teams as needed to facilitate appropriate actions for recoupment of denied/downgraded claims. · Manages assigned workload of accounts so that appeals are submitted timely in accordance with payer timeframes. · Flexible to adjust assignment as Utilization Review Nurse as needed. · Performs other duties as assigned

Requirements

Education: Associate's degree in nursing or higher degree is required. Currently licensed by the state of Alabama.
Experience: Three (3) years of acute care experience or equivalent expertise and two (2) years' experience in utilization review.
Additional Skills/Abilities: Proficient with Microsoft Office suite, Interqual, JIVA, internet and other systems (CMS, Government & commercial payor portals etc.).
Analytical aptitude with the ability to collect, analyze and present data effectively.
Must be a team-player and maintain a positive, resourceful attitude toward achieving the overall departmental and organizational goals.
Strong attention to detail with excellent communication skills in both written and verbal forms.
Ability to work independently and with limited supervision.
Ability to communicate changes effectively, build commitment, and overcome resistance.
Multi-tasking and organization skills
Current BLS

Nice To Haves

BSN preferred.

Responsibilities

Serves as the liaison with government and commercial payers to resolved complex claims, ensure favorable reimbursement, and address other billing or payment issues.
Ability to write articulate and concise appeals by applying clinical knowledge, coding expertise and medical necessity.
Ability to detect trends resulting in denials and constructively report on the root cause to assist in resolution and prevention.
Responsible for evaluating likelihood of receiving a favorable resolution of medical necessity denials, payment discrepancies and contract misinterpretations.
Responsible for clearly documenting actions taken in each patient account.
Collaborates with physicians and interdisciplinary team as appropriate.
Complies with the various payer rules regarding the appeal/denials process.
Communicates with the patient access and billing teams as needed to facilitate appropriate actions for recoupment of denied/downgraded claims.
Manages assigned workload of accounts so that appeals are submitted timely in accordance with payer timeframes.
Flexible to adjust assignment as Utilization Review Nurse as needed.
Performs other duties as assigned