Clinical Appeals Registered Nurse

The primary focus is the analysis of denied services, review of clinical documentation, research of medical literature, and when applicable, the preparation of an effective reconsideration/appeal/dispute in response to a commercial, managed care, governmental, or recovery audit contractors (RAC) requests. Investigate root causes and provide detailed analysis for process improvement initiatives. Utilizes industry guidelines, Medicare Benefit Policy Manual Guidelines, National and Local Coverage Determinations, and best practice standards. Applies a broad knowledge base and sound clinical judgement when responding to denials, audits and/or payer requests. Responds to requests in a timely manner.

Come join a remarkable team where quality care meets quality service, in every dimension, every time.

#JoinTeamAubergine #NovantHealth Let Novant Health be the destination for your professional growth.

At Novant Health, one of our core values is diversity and inclusion. By engaging the strengths and talents of each team member, we ensure a strong organization capable of providing remarkable healthcare to our patients, families and communities. Therefore, we invite applicants from all group dynamics to apply to our exciting career opportunities.

#nursingatnovanthealth

• Education: 2 Year / Associate Degree, required. 
• Experience: Minimum five years experience in a clinical, hospital setting, required.
• Licensure/Certification: Current RN licensure in appropriate state, required.
• Additional Skills (required):
  • Experience reviewing medical documentation, applying acute care criteria sets, and preparing effective appeals.
  • Experience and/or training in Medicare policies and guidelines, commercial insurance policy and guidelines, and best practice standards.
  • Extensive knowledge of medical terminology.
  • The ability to read, interpret, and apply government regulations, commercial contractual agreements, and medical literature.
  • The ability to research, analyze, and problem solve.
  • Effective planning, time management and prioritization skills in order to balance meeting multiple appeal deadlines.
  • Sound clinical judgment.
  • Analyze, trend, and summarize data for root cause analysis and identify opportunities for process improvement and revenue enhancement.
  • Knowledge of Microsoft Office applications (Word, Excel).
• Additional Skills (preferred):
  • Familiar with CPT/HCPCS and ICD-9 coding processes.
  • Utilization Management experience (within the last 3 years).
  • Knowledge of Revenue Cycle.
  • Medical terminology.
  • Experience with Epic.
  • Ability to navigate CMS and Insurance websites for rules and regulations as they pertain to coverage.
  • Researching medical literature.
  • Familiar with Charge Master process.

It is the responsibility of every Novant Health team member to deliver the most remarkable patient experience in every dimension, every time.

• Our team members are part of an environment that fosters team work, team member engagement and community involvement.
• The successful team member has a commitment to leveraging diversity and inclusion in support of quality care.
• All Novant Health team members are responsible for fostering a safe patient environment driven by the principles of "First Do No Harm".