Clinical Review and Appeals Specialist (RN/LPN)

PHI - Quality Care Through Quality Jobs•Phoenix, AZ

19d•Onsite

About The Position

Specialist, Clinical Review and Appeals (RN/LPN) Join Our Life-Saving Team and take advantage of a Sign on bonus up to $7500 while it lasts! Are you ready to elevate your career to new heights? PHI Health is looking for dynamic, driven individuals to join our team. We are committed to providing top-tier emergency medical services with unmatched speed and efficiency, saving lives when every second counts. By supporting our mission from the ground, you will play a crucial role in orchestrating the seamless operations that keep our advanced fleet soaring and our patients safe. With PHI Health you’ll collaborate with the best minds in the industry, driving initiatives that enhance our services and expand our reach to those who need it most. If you're passionate about making a difference and thrive on challenges, PHI Health offers an extraordinary opportunity to impact lives and develop your professional career in a meaningful way. Who We Are: PHI Health is the leading air ambulance provider in the United States. With an unmatched safety record and the best aviation, medical and communication specialists in the field, we set the standard in the air medical industry. We transport more than 22,000 patients each year from our more than 80 bases across the country, all while offering services and outreach education to local communities and leading healthcare systems. Our mission is simple: move communities to health while maintaining the highest standard of safety, period. Position Overview: Under the direction of the PFS Manager, the Specialist, Clinical Review and Appeals will review and address appeal requests for air ambulance transport that were denied for reasons such as medical necessity and prior authorization. Working in the Patient Financial Services NSA division, this position utilizes its clinical expertise to write clinical appeals.

Requirements

Active and unrestricted Arizona Registered Nurse (RN) or Licensed Practice Nurse (LPN) license
3+ years of clinical experience as an RN or LPN.
Must be able to independently prioritize and process a high volume of work.
Must have excellent communication skills as the training of staff on the complexity of payer and regulatory requirements is required.
Maintain the highest level of confidentiality at all times in accordance with HIPAA guidelines and PHI, Inc. and PHI Air Medical, L.L.C. policies.
Adhere to all PHI, Inc. and PHI Air Medical, L.L.C. policies and procedures.
Demonstrate responsiveness and sense of urgency when dealing with payers and internal customers.
Demonstrated expertise in MS Office suite software.
This position is designated Safety Sensitive for purposes of the Arizona Medical Marijuana Act.

Nice To Haves

Air Ambulance, Critical Care or Emergency Room experience preferred
Prior experience in medical claims/appeals writing preferred.

Responsibilities

Review and process appeal letters related to medical necessity for denied air ambulance transport claims submitted to insurance companies.
Collaborate with clinical field staff to resolve documentation issues and ensure all necessary information is collected for appeals.
Conduct thorough reviews of clinical documentation and medical records to determine medical necessity and appropriateness of care.
Communicate with hospitals to obtain appropriate medical records required for thorough appeal processing.
Partner with patient advocacy teams to assist patients in understanding and exercising their appeal rights regarding adverse benefit determinations.
Ensure compliance with federal, state, and payer-specific regulations and guidelines throughout the review and appeals process.
Monitor trends in denials and appeals, identify areas for process improvement, and participate in quality assurance initiatives.
Request and organize supporting documentation to accompany various clinical applications from multiple departments, including but not limited to air ambulance clinical crew.
Perform other duties as assigned.