Registered Nurse (RN) - Clinical Denials & Appeals

About the position

The appeals nurse is responsible for the timely review of denied claims from all payers related to medical necessity, appropriate setting/status determination, authorizations and appropriate length of stay. They will ensure all denied claims are accurately worked and appealed to obtain maximum reimbursement and minimize recoupment. They combine clinical, business and regulatory knowledge and skills to reduce financial risk and exposure caused by concurrent and retrospective denial of payment for rendered services. This position will utilize MCG guidelines, Medicare's 2-midnight rule, and any other payer specific requirement for inpatient, along with the appropriate payer medical policy or NCD/LCD for outpatient services. Medical records may also need to be reviewed for audited claims using the same resources as if the case were denied to prevent recoupment or receive payment related to pre- or post-bill audits. Based on their review, they are responsible for determining whether they will write the appeal, recommend downgrade, or refer to the physician advisors (internal and external) for follow-up. This individual must not only be clinically astute, but well informed on CMS regulations and contract language related to appeal requirements.

Responsibilities

• Review denied claims from all payers related to medical necessity and appropriate setting/status determination.
• Ensure all denied claims are accurately worked and appealed to obtain maximum reimbursement.
• Utilize MCG guidelines and Medicare's 2-midnight rule for inpatient services.
• Review medical records for audited claims to prevent recoupment or receive payment.
• Determine whether to write the appeal, recommend downgrade, or refer to physician advisors.

Requirements

• Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN) with 10 years experience in Case Management, Utilization Review, or Clinical Documentation Improvement.
• 5 years of related work experience within Case Management, Utilization Review, or Clinical Documentation Improvement.