phrn Clinical denials reviewer or interqual inpatient lahug, cebuOmega Healthcare Management Services Inc.

Job Purpose
 
A Clinical Appeals Nurse Specialist is responsible in understanding and analyzing the denials of insurance claims or of coverage for medical treatments or procedures at a healthcare facility and determine whether the denial was warranted or whether to move forward with an appeal.  An appeal is defined as formal, specific, account-level communication issued to a payer to request reconsideration of previously denied services. Communication may be presented in the form of a letter, phone call, online system entry, or other direct payer communication. When services are provided and subsequently denied by insurance companies, all reasonable efforts must be taken to overturn the denial and secure proper reimbursement.
 
 
Job Duties and Responsibilities for Clinical Appeals Nurse Specialist
·       Access account from appropriate work queue and mark account worked to make sure it will not be assigned to another reviewer
·       Review activity summary, documentation, and correspondence to obtain notes related to the denial
o   Review for additional information, such as insurance card, face sheet, detailed bill, Explanation Of Benefits, UB04, auth approval, denial letter
·       Review claim and billing history to isolate any denials related to coding, billing, timely filing, missing or incorrect information
o   Check and note the ff information:
§  Diagnosis Codes, Proc Codes, Payer Name, Denial Code, Authorization,     Bill type, date billed, corrected claims
·       Identify root cause of the denial
·       Work on Medical Necessity and No Authorization denials , and Untimely filing only
·       Review medical records and obtain necessary information to support medical necessity
o   ER, H&P, Physician Orders, Consulatations, Operative Report, Coding Summary, Discharge Summary, Labs, Radiology, MAR, Outside Medical Records, Nurses Notes
·       Utilize Interqual to run assessment or review for Inpatient Medical Necessity
·       Compose appeal letter if appealing the denial
o   Consider the following when selecting the right template:
§  Type of denial
§  Is it a full or partial denial
§  Appeal level being completed
§  Was InterQual met or not
§  Is the denial Inpatient or Outpatient
§  Does payer have contract language
 
§  Are there payer specific considerations
·       Complete the appeal letter
o   Write clinical summary
o   Include presenting symptoms, diagnostics, reason for admission, treatment intervention, hospital course, patient disposition and condition at disposition
o   Include Day by Day clinical progress to support the LOC being appealed or each denied day
 
·       Apply contract language, benefits and covered services in researching and deciding the outcome of appeals
·       Upload and send the letter to the correct fax number/address or Portal
·       Document activity in the client systems
 
 
Required Skills
·       Ability to identify complex problems and reviewing related information to develop and evaluate options
·       Experience with general computer software (Internet, Word, Outlook, PDF required)
·       Proficiency to learn new software programs quickly
·       Excellent customer service skills: communicates clearly and effectively
·       Communicating effectively in writing as appropriate for the needs of the audience
·       Professional and effective interaction skills with co-workers, clients, providers, and vendors
·       Proven ability to work well individually and as a team member
·       Strong attention to detail
·       Ability to follow company and account-specific standard operating procedures and policies
·       Ability to adapt to constantly changing environment
·       Ability to prioritize and organize multiple tasks by remaining focused and quality-driven at all tasks at hand
·       Ability to remain organized with multiple interruptions
·       Ability to make decisions independently without bypassing any company and account-specific standard operating procedures and policies
·       Ability to comfortably receive constructive feedback
·       Advanced Typing skills of at least 50WPM
·       Ability to evaluate and check written text for grammatical and typographical error.
·       Possess strong reading and scanning skills.  
·       Prioritize multiple tasks, work efficiently within time constraints and deadlines and handle stressful situations.
 
Required Experience (PHRN)
 
·       Must be a PH Registered Nurse with min 2 years of clinical nursing or case management experience
·       Minimum of 1 year bedside care experience in an acute setting (Clinics are not included)
·       Minimum 1 year experience in clinical appeals for Inpatient Denials/UR for Inpatient and Continued Stay Reviews
·       Must have an experience in using Interqual for atleast 1 year