Senior Clinical Appeals RN, Phoenix, AZ

Health care isn't just changing.  It's growing more complex every day.  ICD10 replaces ICD9.  Affordable Care adds new challenges and financial constraints.  Where does it all lead?   Hospitals and health care organizations continue to adapt, and we are vital part of their evolution.  And that's what fueled these exciting new opportunities.  
 
Who are we?  Optum360.  We're a dynamic new partnership formed by Dignity Health and Optum to combine our unique expertise.  As part of the growing family of UnitedHealth Group, we'll leverage our compassion, our talent, our resources and experience to bring financial clarity
and a full suite of revenue management services to health care providers nationwide.  
 
If you're looking for a better place to use your passion, your ideas and your desire to drive change, this is the place to be.  It's an opportunity to do your life's best work.SM

• Performs analysis on clinical documentation, evidence-based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials.


• Assures appropriate action is taken within appeal time frames to address clinical denial.


• Collaborates with Patient Financial Services for continued appeal processes.


• Coordinates Clinical Denial follow-up.


• Communicates identified denial trends and patterns to Clinical Appeal Unit Manager.


• Provides expert application of evidence-based medical necessity review tool.


• Utilizes multiple tools (MIDAS+, Veracity, Artiva, etc.) in accurate tracking of clinical denial data. Works collaboratively to review, evaluate and improve the denial appeal process and establish a system-wide uniform process.

Qualifications:

• Current, unrestricted, RN license in AZ


• 3+ years clinical RN experience in a hospital or an acute care setting


• Proficient in computer use and Microsoft applications – must be able to pick up on programs easily


• Must be able to adapt well to change


• Excellent written and verbal communication skills

• Knowledge of CMS regulations


• Experience in Denial Management, Utilization Review, Case Management or related experience


• Experience preparing appeals for clinical denials


• Expertise with InterQual and/or Milliman


• Experience with reimbursement methodologies


• CDC or equivalent coding certification


• Certification in Clinical Documentation Improvement


• BSN degree


• Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement