Registered Nurse Appeals Analyst

Elara Caring•Dallas, TX

3d•Remote

About The Position

At Elara Caring, we have a unique opportunity to play a huge role in the growth of an entire home care industry. Here, each employee has the chance to make a real difference by carrying out our mission every day. Join our elite team of healthcare professionals, providing the Right Care, at the Right Time, in the Right Place. This is a REMOTE POSITION!!! MUST HAVE HOME HEALTH & HOSPICE EXPERIENCE. The Appeals Analyst performs medical record reviews to determine the quality of care, identifies quality issues, and assures compliance with medical record standards and regulatory mandates as related to billing compliance. The incumbent analyzes submitted claims and/or claims to be submitted as well as medical records to determine benefit coverage for medical services under review. This position educates providers on all aspects of medical record criteria to determine benefit coverage for medical services. This position prepares written documents and/or reports of completed medical review determinations and submits records to the payer, as requested.

Requirements

Must be a graduate from an accredited nursing school.
Minimum three (3) years of experience as a registered nurse in a home health and/or hospice clinical care setting is required.
Prior functional working experience in medical records review arena (Utilization Review, Case Management and knowledge of appropriate billing and coding guidelines) is required.
Current License as a Registered Nurse is required.
Interpersonal skills and ability to manage workload and meet deadlines
Demonstrated professional oral and written communication skills
Demonstrated strong organizational skills as well as autonomy with tasks assigned
Demonstrated ability to think critically and adapt to changes
Excellent analytical, problem solving, and negotiation skills
Ability to comprehend medical policy and criteria to clearly articulate health information
Demonstrated ongoing understanding of current Medicare, Medicaid, and third-party regulations as changes occur
Demonstrated knowledge in all levels of home health, hospice, palliative, and home medical equipment practices
Demonstrated proficiency in use of Microsoft Office Suite (Excel, Microsoft Word, Power Point, Outlook)

Nice To Haves

A Bachelor’s Degree in Nursing is preferred.

Responsibilities

Ensures that all activities performed align with the vision of Elara Caring’s board of directors, executive team, and the leadership of the Compliance team.
Promotes compliance with all regulatory standards, through review of medical records.
Maintains productivity, quality, and accuracy targets set by the Governmental Review Manager.
Participates in Administrative Law Judge hearings as the company expert.
Educates providers on all aspects of medical review criteria.
Participates in the appeals process for claims denied by the government or other payers, as necessary.
Collects appropriate medical records, reviews the documentation for validity, and submits the requested documents for pre-claim reviews, ADR requests, and/or appeals.
Collaborates with providers to adhere to clinical standards of care to ensure appropriate outcome.
Practices and adheres to departmental, state, and national guidelines.
Communicates with agencies related to documentation needs in a timely manner and follows up with agency leadership, as needed.
Conducts audits, as needed to ensure documentation adequacy.
Provides education related to audit trends and denials.
Communicates significant findings, problems, and changes related to compliance with documentation standards to the director and other personnel involved with patient care.
Identifies and communicates to Governmental Review Manager and other supervisory personnel visit documentation that lacks adequate content to support billing guidelines.
Participates in the development of strategies/education to prevent loss of revenue during recovery audits.
Assists with development of staff education tools/guides to promote appropriate clinical documentation and utilization.
Writes business letters and reports to explain determinations and decisions to a variety of audiences, including, but not limited to governmental payers, private insurance providers, and administrative law judges.
Participates in all levels of appeal, using regulatory guidance and critical thinking to navigate appeals compliantly.
Promotes, coordinates, and evaluates operational Systems to enhance operations and promote efficiencies.
Provides leadership to team and support staff in identifying agency/client needs and opportunities for improvement.
Promotes Elara Caring’s philosophy, mission statement and administrative policies to ensure quality of care.
Maintains patient and staff privacy and confidentiality pursuant to HIPAA Privacy Final Rule.
Performs other duties/projects as assigned.