Clinical Denial/Appeals RN

Guidehouse•New York, NY

2d•$81,000 - $135,000

About The Position

The Clinical Denials RN is responsible for review, analysis and appeal of clinical denials from insurance companies and third-party payers. This role requires a strong clinical background, knowledge of medical necessity criteria, and expertise in appealing denied claims. Essential Job Functions: Medical Necessity Reviews Ensure documentation integrity Construct warranted appeals Coordinate pre-service authorization approvals

Requirements

Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree)
Current Registered Nursing License
4+ years of prior clinical experience

Nice To Haves

Legal Nurse Consultant Certification
Cerner/Epic Superuser
Nurse Auditor Experience
CV/DRG Appeal Experience
Medical/Legal Nursing Experience

Responsibilities

Conduct comprehensive Denial Root-cause analysis
CV DRG Reviews
Medical/Legal Reviews
Retrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present to support medical necessity
Collaboration with hospital Patient Access and Mid-Revenue Cycle
Research and application of regulatory policies to support clinical appeal
Telephonic communication with payors, provider, hospital staff and patient/family as necessary to bring the account into resolution.
Technical ability to multi-task on various systems, desktop and Microsoft applications while managing inbound calls
Working knowledge of basic Coding Guidelines
May be required to present oral presentations to client facility or Guidehouse staff and leadership
Attention to detail, strong organizational skills and self-motivated.
Ability to make decisions and assimilate multiple data sources or issues related to problem solving independently & accurately
Ability to work under a timeline/deadline & provide clear & accurate update to project leader of assignment progress, hours worked & expected outcomes daily
Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial
Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service

Benefits

Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
Short-Term & Long-Term Disability
Tuition Reimbursement, Personal Development & Learning Opportunities
Skills Development & Certifications
Employee Referral Program
Corporate Sponsored Events & Community Outreach
Emergency Back-Up Childcare Program