Clinical Appeals Nurse

THE POSITION:

The Clinical Appeals Nurse is responsible for managing medical denials by conducting a comprehensive review of clinical documentation to determine if medical necessity criteria are met. Where an appeal is warranted, the Clinical Appeals Nurse consults with healthcare providers, patients and the medical record to compose sound, compelling, factual arguments for submission. They manage the appeals process within prescribed timeframes in order to meet the operational goals of the department. Attendance at Administrative Law Judge Hearings may be required.ESSENTIAL DUTIES AND RESPONSIBILITIES:

Our employees are tasked with delivering excellent business results.  These results are achieved by:Successfully managing the appeals process from beginning to end within the designated timeframeEnsuring appropriate communication through the process with patient, insurance company and internal business partnersEnsuring compliance with HIPAA regulations, to include confidentiality, as requiredAll other duties as assignedReasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. EXPECTATIONS OF THE JOB:Determine why cases are denied and if an appeal is warranted using knowledge of payer requirements with medical chart dataUtilize pre-existing criteria, clinical evidence and other resources as needed to develop sound and well-supported appeal argumentsGenerate appropriate appeal resolution communication to the member and provider in accordance with company policiesRequest additional information from providers, as appropriate, to facilitate timely appealsGather and prepare case information for participation in Administrative Law hearingsSummarize and present appeal outcomes to clients and participate in client meetings as neededReviewing documentation related and level of care decisions with clientsThe above list reflects the general details necessary to describe the expectations of the position and shall not be construed as the only expectations that may be assigned for the position.An individual in this position must be able to successfully perform the expectations listed above.