USRN with interqual inpatient experience onsiteOmega Healthcare Management Services Inc.

 USRN WITH INTERQUAL INPATIENT EXPERIENCE ONSITE ( LAHUG CEBU)
 
Required Experience (USRN)
 
Qualifications:
Must be a US Registered Nurse
Minimum of 1 year bedside care experience in an acute setting ( clinics are not included)
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
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
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
ER, H&P, Physician Orders, Consultations, 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
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