Clinical Denials and Appeals RN - Remote

Job Family:

Clinical Appeals Nurse

Travel Required:

None

Clearance Required:

None

What You Will Do:

The Remote Clinical Denials/Appeals Nurse will be directly responsible for securing pre-service approvals, and reviewing pre/post service denials, medical necessity review and completing appeals and/or coordinating peer to peer reviews as appropriate. This position will perform all related job duties as assigned.

Essential Job Functions:

• Medical Necessity Reviews.

• Ensure documentation integrity.

• Construct warranted appeals.

• Coordinate pre-service authorization approvals.

• Conduct comprehensive Denial Root-cause analysis.

• 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.

• Utilize Evidence -based clinical guideline tool (Milliman ® or InterQual ®).

• 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 updates 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.

• 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 updates 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.

What You Will Need:

• Current Registered Nursing License.

• Minimum of 5 years clinical experience

• Clinical Denials Experience required

What Would Be Nice To Have:

• Utilization Review experience a plus

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The annual salary range for this position is $65,400.00-$98,200.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, …