Revenue cycle clinical appeals nurseVISAYA

Job Description
The Revenue Cycle Clinical Appeals Nurse is the liaison and point of contact for clinical denials and appeals that are received after claim submission. Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care.
Includes, But Is Not Limited To The Following
Use their clinical knowledge, experience, and advanced critical thinking to ensure accuracy and integrity of the full life cycle of medical necessity denial determinations is properly administered
Evaluate clinical appeal letter correspondence for content, clarity, accuracy, and consistency
Package & send appeal and grievance information to the payors, monitors for the outcome of appeal and takes action accordingly (notify the provider and member as per delegation agreement), track all appeal information
Actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials
Participate in the review of audit findings as needed
Minimum Qualifications
Ability to project a professional image
Apply professional standards of practice in the work environment to both internal and external customers
Knowledge of regulatory standards, compliance requirements, hospital policies and procedures, and third party requirements
Familiar with medical terminology
Strong understanding and working knowledge of Medicare and Commercial admission regulations
Familiar with third-party admission and continued stay criteria
Working knowledge of personal computer and software applications used in job functions (Word processing, graphics, databases, spreadsheets, etc.)
Education And/or Experience
A minimum of two years of Utilization Review/Case Management experience in either a managed care or hospital setting is required
A minimum of two years experience in the denial and appeal process preferred
Certificates, Licenses, Registrations
RN license, in good standing and maintained current throughout employment
CCM, preferred