[Hiring] Clinical Appeals Nurse @Jefferson Health Plans

Role Description

The Clinical Appeals Nurse is responsible for the following:

• Reviews payor denials and audits for potential lost revenue.
• Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity.
• Functions as a hospital liaison with external third-party payors to appeal denied claims.
• Works closely with the Physician advisor team to facilitate appeals to payors.
• Monitors and reports payor trends to the management team.
• Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor and the documentation found in the hospital/physician information system.
• Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor to meet their guidelines.
• Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials.
• Contacts insurance companies and conducts appeals via telephone or email.
• Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights.
• Identifies areas for revenue loss due to documentation or processes not being reimbursable through payors.
• Ensures that all appeals are sent to the correct payor within the appeal guidelines.
• Ensures compliance with regulatory and accrediting requirements.
• Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor.
• Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

Qualifications

• Registered Nurse (RN) license required.
• Experience in clinical appeals and insurance processes preferred.
• Strong analytical and communication skills.
• Ability to work independently and as part of a team.

Requirements

• Full-time remote position.
• Workday Day (United States of America).
• Regular employee status.

Benefits

• Comprehensive medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance.
• Short- and long-term disability.
• Flexible spending accounts.
• Retirement plans.
• Tuition assistance and discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.
• Access to group rates on insurance and discounts for voluntary benefits.
• Medical (including prescription) insurance available for all colleagues, including those working less than part-time.