Required Experience (USRN)
 
1.Must be a US Registered Nurse
2.Minimum of 1 year bedside care experience in an acute setting ( clinics are not included)
3.Minimum of 1 year experience in clinical appeals for Inpatient Denials/ UR for interqual and continued stay reviews
 
 
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
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Omega Healthcare Management Services Inc.
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