Clinical Appeals Specialist RN
Offer summary
Qualifications:
Licensed as a Registered Nurse (RN) in the State of Washington., Experience in clinical, health insurance, coding/claims review, or case management setting., Strong written and verbal communication skills with attention to detail., Ability to interpret regulatory guidance and payer specific policies..Key responsibilities:
- Review and resolve clinical claim denials and audit determinations.
- Develop and write appeal rationales supported by medical documentation.
- Analyze trends from audits and denials for process improvement.
- Collaborate with internal and external partners to align clinical criteria with payer guidelines.
Job description
Description
Wage Range: $43.26 - $69.22 per hour
Posted wage ranges represent the entire range from minimum to maximum. For jobs with more than one level, the posted range reflects the minimum of the lowest level and the maximum of the highest level. Some positions also offer additional premiums based on shift, certifications or degrees. Job offers are determined based on a candidate's years of relevant experience, level of education and internal equity.
Please Note: This is a remote position; however, due to our pay practices, qualified candidates must reside in the State of Washington. While work is remote, candidates must have reliable broadband internet and personal cell phone service. Remote work may involve regular operations during Pacific Time business hours and participation in online training
Job Summary
Responsible for the review and appeal of clinical claim denials and audit determinations for the hospital. Utilizes clinical expertise to interpret documentation and write appeals that utilize nationally recognized criteria to support the medical necessity of services billed. Understands and references Medicare and commercial payer policies to support appeal rationales. Communicates and coordinates effectively with all levels of the organization and payer representatives. Analyzes trends and collaborates with internal and external partners to identify opportunities to reduce denials by improving processes.
Responsible for the review and appeal of clinical claim denials and audit determinations for the hospital. Utilizes clinical expertise to interpret documentation and write appeals that utilize nationally recognized criteria to support the medical necessity of services billed. Understands and references Medicare and commercial payer policies to support appeal rationales. Communicates and coordinates effectively with all levels of the organization and payer representatives. Analyzes trends and collaborates with internal and external partners to identify opportunities to reduce denials by improving processes.
Primary Duties:
1. Responsible for the review and resolution of clinical claim denials and audit determinations.
2. Applies clinical expertise and judgment to determine the medical necessity of services billed and compliance with payer policies and guidelines.
3. Develops and writes appeal rationales that are supported by medical record documentation and nationally recognized clinical criteria.
4. Interprets and applies payer specific policies, guidelines, and contract terminology to develop clinical rationale to support medical necessity of services provided, patient status determinations and readmission reviews.
5. Coordinates with Medical Director(s) to clarify medical determinations or clinical rationale.
6. Analyzes trends from audits and denials and presents to stakeholders for education and process improvement. Assists with the development of reports as needed to investigate denial issues.
7. Collaborates with Care Management to align clinical criteria and definitions from admission through appeal with payer guidelines to reduce denials.
8. Participates in the Audit and Denials Committee along with other key stakeholders.
9. Maintains and continually enhances clinical skills, staying current with changes in guidelines and regulations.
10. Performs other duties as assigned.
1. Responsible for the review and resolution of clinical claim denials and audit determinations.
2. Applies clinical expertise and judgment to determine the medical necessity of services billed and compliance with payer policies and guidelines.
3. Develops and writes appeal rationales that are supported by medical record documentation and nationally recognized clinical criteria.
4. Interprets and applies payer specific policies, guidelines, and contract terminology to develop clinical rationale to support medical necessity of services provided, patient status determinations and readmission reviews.
5. Coordinates with Medical Director(s) to clarify medical determinations or clinical rationale.
6. Analyzes trends from audits and denials and presents to stakeholders for education and process improvement. Assists with the development of reports as needed to investigate denial issues.
7. Collaborates with Care Management to align clinical criteria and definitions from admission through appeal with payer guidelines to reduce denials.
8. Participates in the Audit and Denials Committee along with other key stakeholders.
9. Maintains and continually enhances clinical skills, staying current with changes in guidelines and regulations.
10. Performs other duties as assigned.
License, Certification, Education or Experience:
REQUIRED for the position:
● Licensed as a Registered Nurse (RN) in the State of Washington.
● Experience in clinical, health insurance, coding/claims review, or case management setting.
● Strong written and verbal communication skills.
● Must be highly detail oriented.
● Must have superior organizational skills.
● Ability to understand and interpret regulatory guidance, contract language, and payer specific policies.
● Ability to make decisions with respect to his/her delegated responsibilities.
● Experience with payer audits, authorization review processes, and/or claim denials.
● Licensed as a Registered Nurse (RN) in the State of Washington.
● Experience in clinical, health insurance, coding/claims review, or case management setting.
● Strong written and verbal communication skills.
● Must be highly detail oriented.
● Must have superior organizational skills.
● Ability to understand and interpret regulatory guidance, contract language, and payer specific policies.
● Ability to make decisions with respect to his/her delegated responsibilities.
● Experience with payer audits, authorization review processes, and/or claim denials.
DESIRED for the position:
● Bachelor’s degree in a healthcare or related area.
● 3 years of clinical nursing and/or case management experience
● Knowledge of MCG (fka Milliman), InterQual, or other admission guideline tools.
● Epic EMR experience.
● General knowledge of healthcare revenue cycle including familiarity with reimbursement methodology, charge capture and billing processes.
● Bachelor’s degree in a healthcare or related area.
● 3 years of clinical nursing and/or case management experience
● Knowledge of MCG (fka Milliman), InterQual, or other admission guideline tools.
● Epic EMR experience.
● General knowledge of healthcare revenue cycle including familiarity with reimbursement methodology, charge capture and billing processes.
Benefit Information:
Choices that care for you and your family
Choices that care for you and your family
At EvergreenHealth, we appreciate our employees’ commitment and contribution to our success. We are proud to offer a suite of quality benefits and resources that are comprehensive, flexible, and competitive to help our staff and their loved ones maintain and improve health and financial well-being.
• Medical, vision and dental insurance
• On-demand virtual health care
• Health Savings Account
• Flexible Spending Account
• Life and disability insurance
• Retirement plans (457(b) and 401(a) with employer contribution)
• Tuition assistance for undergraduate and graduate degrees
• Federal Public Service Loan Forgiveness program
• Paid Time Off/Vacation
• Extended Illness Bank/Sick Leave
• Paid holidays
• Voluntary hospital indemnity insurance
• Voluntary identity theft protection
• Voluntary legal insurance
• Pay in lieu of benefits premium program
• Free parking
• Commuter benefits
• On-demand virtual health care
• Health Savings Account
• Flexible Spending Account
• Life and disability insurance
• Retirement plans (457(b) and 401(a) with employer contribution)
• Tuition assistance for undergraduate and graduate degrees
• Federal Public Service Loan Forgiveness program
• Paid Time Off/Vacation
• Extended Illness Bank/Sick Leave
• Paid holidays
• Voluntary hospital indemnity insurance
• Voluntary identity theft protection
• Voluntary legal insurance
• Pay in lieu of benefits premium program
• Free parking
• Commuter benefits
View a summary of our total rewards available to you as an EvergreenHealth team member by clicking on the link below.
#LI-EK1
Required profile
Experience
Spoken language(s):
English
Check out the description to know which languages are mandatory. Other Skills
- Decision Making
- Communication
- Organizational Skills
- Detail Oriented
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