Clinical Denials and Appeals RN - Remote
Home Office: Birmingham, AL
Job Family:
Clinical Appeals Nurse
Travel Required:
Clearance Required:
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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Benefits/Perks401(k) Plan 401(k) Retirement Plan Basic Life & Supplemental Life Childcare Program Company paid holidays Corporate Sponsored Events & Community Outreach Dental Dental Insurance Disability Insurance Emergency Back-Up Childcare Program Employee Referral Program Flexible Spending Accounts Health savings account Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts Life Insurance Medical Medical Insurance Medical, Rx, Dental & Vision Insurance Paid holidays Parental leave Personal and Family Sick Time Personal and Family Sick Time & Company Paid Holidays Rx Sick time Skills development Skills Development & Certifications Tuition reimbursement Tuition Reimbursement, Personal Development & Learning Opportunities Variable Incentive Bonus Vision Vision Insurance
Tasks- Communication
- Training
Coding Coding Guidelines Communication Medical Record Review Medical Records Microsoft Applications Organizational Problem-solving Telephonic Communication Training
Experience5 years
Education Timezones