The job below is no longer available.

You might also like

in Easton, PA

Use left and right arrow keys to navigate
Hours Full-time, Part-time
Location Easton, PA
Easton, Pennsylvania

About this job

The Clinical Appeals Nurse reviews denied claims and appeals to the health plan to recover payment for medical necessity, authorization and level of care denials. Review all assigned inpatient denials; obtain additional information as needed to file clinical appeals necessary to resolve payor denial of reimbursement on inpatient, outpatient or observation claims. Communicate clinical denial information to appropriate departments and/or personnel for follow up and educational purposes. Maintenance and upkeep of inpatient denial pools and documents as required 1 File medical necessity and level of care appeals u sing InterQual and CMS guidelines 2 Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures . 3 Track and manage clinical denials using current tools (manuals, training programs). 4 Identify patterns and trends in denials; communicate to appropriate persons. 5 Maintain documentation regarding all payor resources regarding denials and appeals processes. 6 Observe professional ethics in maintaining confidential information acquired concerning the personal, financial, medical or employment status of patients (and their families) provided services by the hospital. 7 Follow and enforce accepted safety practices for patients and the hospital. Report safety hazards and initiate appropriate action. Participate in safety instructional programs. 8. Observe excellent customer service skills when dealing with patients, families and/or significant others, outside vendors, coworkers, and physicians. 9. Attend both mandatory and elective educational offerings to enhance professional performance 10. Provide education to staff as appropriate 11. Be familiar with policy and procedure manuals and other reference materials. . 12 Other duties assigned by Manager or Department Director 2.0 General Responsibilities 1 Demonstrates excellent technical and creative writing skills 2 Assists in the development of policies and procedures for all audit & denial appeals processes. 3 Works with all members of the HMA audit & denial appeals team to support denial appeals generation whether completed at the hospital level, home office level, or externally by contracted companies. 4 Serves on various committees and task forces related to RAC and other payer audits when so directed by the Director. 5 Ensures that the Director is kept informed of important issues and problems. 6 In collaboration with the Director, must maintain current up-to-date knowledge of legislative, CMS, state Medicaid, other payers (including commercial and Medicare HMOs), and other governmental audit current trends in audits and denials. 7 Assists with the orientation of new associates and provides for ongoing education, under the direction of the Director. SUB SECTION STANDARDS TOTAL: 6.0 Interpersonal/Communications/Relationships 6.1 Effectively utilizes verbal and written communication skills. Ability to read and communicate effectively. 6.2 Keeps m anager informed of department based needs. 6.3 Understands cultural diversity and demonstrates an understanding of the value of all members of the healthcare team. 6.4 Ability to take action and get things done independently. Assumes responsibility promptly and effectively. Identifies the issue, develops steps and participates as needed to resolve the issue. 6.5 Demonstrates tact when dealing with patients, colleagues and the public 6.6 Demonstrates ability to address issues and find a solution while at the same time achieving consensus with the individuals involved. 6.7 Adheres to the proper "chain of command" within the organization. (Rated either 5 or 1) 7.0 Information Management/HIPAA 7.1 Maintains confidentiality required in patient and peer relationships in the healthcare community as relevant to position. 7.2 Demonstrate knowledge of procedures for maintaining security, confidentiality and integrity of patient medical information. 7.3 Demonstrates skills and accuracy in collecting and inputting data into hospital computer system as relevant to position. 8.0 Equipment/Resources 8.1 Demonstrates skill in use of equipment relevant to position, knowledge of appropriate safety procedures. 8.2 Diagnosis equipment problems, repairs or seeks out someone to repair. 8.3 Consistently inform appropriate person of problems encounter with repairs or calibration of equipment Must have a diploma/degree from an accredited school of nursing. LPN or RN with current license to practice in state. * At least 3 years of experience as a hospital-based nurse is required. * At least 3 years of experience as a Case or Resource Manager is desired. * Minimum 2 years acute care hospital inpatient coding and or charge auditing experience is preferred. * Minimum 1 year experience with medical necessity appeals at all levels is preferred. Must possess a current nursing license (RN/LPN)