Denials Management Appeals Nurse (Anesthesia)

Shriners Children's•Remote,

1d•Remote

About The Position

The Denials Management Appeals Nurse (Anesthesia) is responsible for managing medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. This role utilizes a clinical background to address clinical denials and write compelling factual arguments for appealing denials. The position also requires maintaining detailed knowledge of Third Party Payors and Governmental Payors' clinical/medical necessity criteria and filing compliant appeals in accordance with contracts.

Requirements

5 years of clinical healthcare/hospital experience
3 years of related Anesthesia experience
Third Party Payor Appeals/Revenue Cycle experience
Current RN license in State of employment
Working experience with Utilization Review activities and general knowledge of TJC, PRO, and other regulatory bodies.

Nice To Haves

Bachelor’s degree - BSN highly desired
Case Management certification
Experience reviewing hospital and professional claims, denials and EOB's, appealing claims and working on claims in an audit
Experience with Epic, Craneware, Waystar, software and applications

Responsibilities

Performs a review of assigned cases comparing the bill to the medical record.
Performs a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process.
Performs a detailed comparison of charges to documentation to ensure services not documented are not charged.
Reviews documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur.
Review findings with the hospital representatives and obtains an agreement on the discrepancies.
Demonstrates tact and understanding in handling problems, has a good rapport with hospital and corporate staffs.
Follows up on appeals in a timely fashion to ensure that cases are completed.
Re-checks mathematical computations before finalizing letter and report.
Updates status of all cases assigned on minimum weekly basis.
Informs supervisor of any changes, problems, or concerns that arise at a facility.
In the event of a dispute with the requesting party’s audit findings, files an appeal with the third party or governmental payor.
Analyzes and interprets all medical necessity/clinical denials from third party payors or governmental payors.
Files appeals based on medical documentation and interpretation of medical necessity guidelines or InterQual criteria.
This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned.

Benefits

Medical coverage on their first day
403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service
Paid time off
Life insurance
Short term and long-term disability
Flexible Spending Account (FSA) plans
Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected
Tuition reimbursement
Home & auto
Hospitalization
Critical illness
Pet insurance