[Hiring] Clinical Appeals Nurse @Jefferson Health Plans

Role Description

Clinical Appeals Nurse - Full Time Remote - Jefferson Health

• 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 Physician advisor team to facilitate appeals to payors.
• Monitors and reports payor trends to 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 thru 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

• Education - Required: Bachelor’s Degree Nursing or Specialized Diploma
• Experience - Required: 10 years of clinical or case management/utilization review experience
• Knowledge, Skills and Abilities - Required:
  • Ability to read medical charts and identify deficiencies in documentation content.
  • Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
  • Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
  • Knowledge of coding for payment of claims.
  • Insurance knowledge of payors and their unique rules.
  • Epic workflow experience with notes in account history and WQ workflows.
  • Intermediate Excel and MS Word experience.
  • Must complete RCE Training and pass test with 80% or better.
• Licenses and Certifications - Required: RN - Licensed Registered Nurse_PA - State of Pennsylvania

Benefits

• Comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits.
• Access to tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.