[Hiring] Clinical Appeals Review RN, DRG @Managed Resources

Role Description

The Clinical Appeals Review Nurse reviews and analyzes denied/downgraded MS-DRG and APR-DRG and APC accounts received from all types of payers (e.g., Medicare, Commercial, and Third Party). Utilizing clinical and coding expertise, the Nurse will render determination on whether the denied/downgraded account is appealable based on the standards of each client.

Behind every denied claim is a clinical decision that deserves a thorough and objective review. As a Clinical Appeals Review RN DRG, your expertise plays a vital role in identifying opportunities to overturn denials.

After review of the denial and medical record, the Clinical Appeals Review Nurse will provide either a reasoned explanation why no appeal can be written, or a detailed appeal letter based on current coding and regulatory guidelines and clinical criteria. In either case, the Nurse will then track and trend MRI defined denial root causes for each specific denial.

Qualifications

• Registered Nurse (BSN preferred)
• CCS, CPC, CCDS, or RHIT Certification is required
• Graduate of an accredited College or University, BSN is preferred
• 5+ years of clinical experience in Hospital inpatient and outpatient departments
• 2+ years of clinical appeals/denials writing experience
• Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG and APC medical records and accounts received from payers (e.g., Medicare, Commercial, and Third Party)
• Experience in a variety of Electronic Medical Records (EMR) Systems, i.e. (3M, Nuance, Epic, etc)

Requirements

• Conduct secondary quality reviews of clinical appeal letters to ensure accuracy, clinical soundness, and compliance with coding, payer, and regulatory requirements prior to submission.
• Perform efficient analysis of denied claims, pinpointing reason for denial and potential for success of appeal including correct allocation of diagnostic and procedural codes under ICD-10 Official Coding Guidelines and ICD-10 Procedural Coding Guidelines, 3M APR-DRG Classification System, CPT, HCPCS, Revenue Code, and all associated authorities such as CMS regulations, statutes, and associated authorities such as AHA Coding Clinics and CPT Assistant.
• Write clear and concise grammatically correct appeals letter in MRI format and to MRI quality standards.
• Be aware of the level of appeal, level of future appeals available and write according to the level of appeal.
• Utilize current applicable clinical, legal, and coding standards.
• Understand and strictly comply with time deadlines; write appeals in an efficient and timely manner.
• Provide a reasoned root cause analysis and summary review for all clients within MRI standard.
• At all times observe all HIPAA standards.
• Obtain and maintain client computer accesses.
• Participate in preparation of clear and concise audit report, as needed.
• Stay current in clinical, coding, and appeal writing areas and comply with MRI quality recommendations to maintain efficient and effective processes.
• Identify coding and clinical documentation issues and provide proactive recommendations through manager to clients.
• Identify problem account and seek review or return to client through manager, as appropriate.
• Clearly and concisely update patient account record to identify actions taken on account.
• Responsible to work through manager to liaise with third party payer and agencies regarding appeals to ensure optimal reimbursement and resolve billing issues, contract misrepresentations and payment discrepancies.

Benefits

• Medical, Dental, and Vision Insurance
• Phone and Internet Stipend
• Company-Paid Life Insurance
• 401(k) Retirement Plan with Company Match
• Paid Time Off
• Seven Company-Observed Holidays
• Two Floating Holidays for Personal Observance
• Professional Development Opportunities
• Employee Recognition Programs
• Remote Work Environment