Clinical Appeals Nurse

Remote position

GENERAL SUMMARY:

Responsible for completing retrospective Clinical Appeals for full or partially denied claims for Managed Care, Government, Non-Government and Commercial payors when the third-party payors do not meet the expected payment as modeled. The Clinical Appeals Nurse will write comprehensive, factual arguments to present to third party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. This position reports to the Manager, Denials.

ESSENTIAL DUTIES:

1. Understands the revenue cycle and the responsibility and goals of each area and how their role impacts the system.

2. Analyzes clinical denial/audit review patient medical records, utilizing clinical and regulatory guidelines, and applying knowledge of payer requirements to determine why cases are denied and whether an appeal is required.

3. Utilizes established clinical criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments.

4. Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

5. Collaborates with Case Management, HIM and/or other team members to determine appropriate responses when necessary.

6. Contacts insurance companies to conduct telephonic or electronic appeals, if applicable.

7. Elevates appeals to the appropriate manager/committee when necessary.

8. Provides relevant feedback to applicable departments, related to denial root cause analysis and denial prevention.

9. Ensures compliance with HIPAA regulations, to include confidentiality and integrity as required.

10. Identifies and refers cases appropriately for Case Management, Quality Improvement for education and process improvement.

11. Understands and applies payer specific appeal guidelines and elevates cases for payer peer to peer reviews.

12. Participates in all educational activities, and demonstrates personal responsibility for job performance.

13. Maintains a professional image and provides excellent customer service.

14. Attends department meetings and education sessions.

15. Meets/exceeds performance expectations within required timeframes.

16. Practices and adheres to the “Code of Conduct” philosophy, Mission, and Values statement.

17. Adheres to all Beaumont Health Policies and Procedures.

18. Performs other duties as assigned.

STANDARD REQUIREMENTS:

1. Supports the Mission, Values and Vision of Beaumont Health. Demonstrates personal commitment through active involvement in the performance improvement process.

2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.

3. Supports and adheres to all Beaumont Health’s customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code.

4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information.

5. Supports and participates in a collaborative team oriented environment – cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.

6. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules – including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.

7. Completes all required compliance standards that may be department specific and/or identified by the organization.

8. Maintains current licensure, registration and/or certification, as applicable, at all times.

STANDARD QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

A. Education / Training:

· Bachelors in Science required

· Bachelor’s degree in Nursing preferred

B. Work Experience:

· Minimum of two (2) years related experience in health care.

· Background in Case Management preferred.

· Must be familiar with revenue cycle structure and process.

C. Certification, Licensure, Registration:

·RN

D. Other Qualifications:

· Must be detail oriented and must possess excellent time management and organizational skills.

· Strong verbal and written communication skills.

· Proficiency in Excel, Word, PowerPoint and Access is necessary

· Requires critical thinking skills, problem solving, decisive judgment, ability to work with minimal supervision and must possess excellent time management and organizational skills. Must be able to work in a stressful environment and take appropriate action.

· PC skills- demonstrated proficiency in Microsoft Office applications and others as requires.

· Policies and Procedures- demonstrates knowledge and understanding of organizational policies, procedures and systems.

· Basic skills- able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately.

· Technology skills- requires knowledge of computer systems, operating systems, networks and common software packages available to support database and spreadsheet applications. General knowledge of relevant system support and troubleshooting.

· Customer orientation- established and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.

WORKING CONDITIONS:

A. Physical Effort:

· Strength: Position requires incumbent to infrequently perform physical activities requiring ability to push/pull objects up to 20 pounds and occasionally lift objects of up to 30 pounds.

· Manual Dexterity: Position requires incumbent to frequently perform simple motor skills such as answering a telephone, frequently perform simple and moderately difficult manipulative skills such as writing and typing.

· Coordination: Position requires incumbent to frequently perform gross body coordination such as walking, filing, retrieving manuals, frequently performing tasks which require eye-hand coordination such as keyboard skills.

· Mobility: Position requires incumbent to frequently perform mobility skills such as walking, standing, sitting and occasionally perform prolonged sitting. Must be able to push a patient in a wheelchair and walk throughout shift to support clinical departments and assist patients/families as needed.

· Visual Discrimination: Position requires incumbent to frequently see objects far away such as locating a client company and to discriminate colors in industrial signs; occasionally to see objects closely as in reading faces or dials.

· Hearing: Position requires incumbent to constantly be able to hear normal sounds with some background of noise and to distinguish sounds as voice patterns in telephone conversations with clients.

B. Work Environment:

· Position require incumbent to be exposed to a variety of substances within the home office environment, corporate facilities and other sites such as electro-magnetic radiations as in VDT’s and occasionally to dust.

· This job description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this job description. The individual(s) may be called upon and required

to follow or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives

Beaumont offers a comprehensive benefits package to meet your financial, health and life-work balance goals.

NEW On-demand pay program – powered by Payactiv

Generous paid time off, holidays and flexible scheduling

Our employees receive special discounts on a wide range of products and services

Exceptional health, dental, vision and prescription drug insurance plans

Relocation assistance

Generous retirement savings, disability insurance, identify theft protection and even home and auto insurance

Our diverse and talented teams of professionals and clinicians don’t just share in the success of our system; they make it possible. Driven by our shared commitment to making our communities healthier and stronger, we are leading the way in health care innovation with relentless ambition and a belief that anything is possible when we work together. 

This is where extraordinary begins. Find out where it can take you and your career.  Apply Now!

Beaumont Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.