Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility.
EDUCATION: Graduate of an accredited School of Nursing with an Associate or Bachelor's degree (Preferred) in nursing.
CERTIFICATION/LICENSES: Current RN Nursing license
Interqual and/or MCG certification preferred. Case Management (CCM) or Managed Care certification preferred
- Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task
- Intensive writing capabilities/efficiencies
- Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff)
- Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomes
- Assertive and diplomatic communication, proven ability to function on a multidisciplinary team
- Excellent organizational skills including effective time management, priority setting and process improvement
- Ablility to apply InterQual and Milliman Care Guidelines (MCG) medical necessity criteria to a case as applicable
- Understanding of Medicare, Medicaid and third party reimbursement methodologies
- Ethics and Values -- Adheres to an appropriate (for the setting) and effective set of core values and beliefs during both good and bad times; acts in line with those values; rewards the right values and disapproves of others; practices what he/she preaches
- Creativity -- Comes up with a lot of new and unique ideas; easily makes connections among previously unrelated notions; tends to be seen as original and value-added in brainstorming settings
- Customer Focus -- Is dedicated to meeting the expectations and requirements of internal and external customers; gets first hand customer information and uses it for improvements in products and services; acts with the customers in mind; established and maintains effective relationships with customers and garnishes their trust and respect.
- Decision Quality -- Makes good decisions (without considering how much time it takes) based upon a mixture of analysis, wisdom, experience, and judgment; most of his/her solutions and suggestions turn out to be correct and accurate when judged over time; sought out by others for advice and solutions.
- Drive for Results -- Can be counted on to exceed goals successfully; is constantly and consistently one of the top performers; very bottom-line orientated; steadfastly pushes self and others for results.
- Peer Relationships -- Can quickly find common ground and solve problems for the good of all; can represent his/her own interests and yet be fair to other groups; can solve problems with peers with a minimum of noise; is seen as a team player and is cooperative; easily gains trust and support of peers; encourages collaboration; can be candid with peers.
- Priority Setting -- Spends his/her time and the time of others on what's important; quickly zeros in on the critical few and puts the trivial many aside; can quickly sense what will help or hinder accomplishing a goal; eliminates roadblocks; creates focus.
EXPERIENCE: Two to four years of Case Management experience. Two to three years' experience in the denial and appeal process. Experience with managed care, governmental and/or RAC appeals strongly preferred. Computer experience in Microsoft Office (Word and Excel).
NATURE OF SUPERVISION:
-Responsible to: Director of Case Management
-Bloodborne pathogen: A
Works in a clean, well-lighted, ventilated smoke-free environment.
PHYSICAL REQUIREMENTS: Vision acuity at least 20/40; hearing acuity at least conversational; color perception. Lift/Carry objects more than 40 lbs. per day.