Clinical Appeals Specialist Pd

The Clinical Appeals Specialist
reports to the Manager Appeals. Under
general supervision and within Lifespan policies and procedures works
collaboratively with The Miriam Hospital and Rhode Island Hospital and multiple
system-wide departments. Is responsible
for review of medical records to ascertain appeal information and for the
development of appeal correspondence.
Analyzes clinical denials based on severity of illness and intensity of
service using InterQual criteria and Center for Medicare and Medicaid Services
(CMS) guidelines. Analyzes and reports
data of audits at the facility and system-wide level. Provides education to Lifespan staff and
physicians to reduce future audit exposure.

mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Consistently applies the
corporate values of respect honesty and fairness and the constant pursuit of
excellence in improving the health status of the people of the region through
the provision of customer-friendly geographically accessible and high-value
services within the environment of a comprehensive integrated academic health
system. Is responsible for knowing and
acting in accordance with the principles of the Lifespan Corporate Compliance
Program and Code of Conduct.

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Is responsible for the hospitals
appeals initiative by coordinating governmental and third party appeals with
attending physicians and the medical director.

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Collaborates with government
oversight agencies and third party payers regarding audits.

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Prepares reviews develops and
maintains various manual and computerized documentation. Records and reports vital statistics on the
denials and appeal data. Ensures
completeness and accuracy.

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Prepares and presents high level
professional presentations.

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Participates on various hospital
state and department committees to provide input for development of policies
and procedures related to audits and appeals.

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Participates in ongoing
independent study education-related professional activities and affiliations
to maintain knowledge of government and commercial payer regulations and
reimbursement issues.

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minor-latin;color:black;mso-themecolor:text1">Researches and identifies
opportunities for improvement and submits recommendations to manager and/or
director.

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minor-latin;color:black;mso-themecolor:text1">Conducts retrospective reviews
and audits of hospital records to determine if level of care is appropriate and
sufficiently documented

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Works collaboratively at all
levels of the organization

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Participates in or leads various
committees task forces and quality improvement teams as needed.

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minor-latin;color:black;mso-themecolor:text1">Performs other duties as
assigned.

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minor-latin;color:black;mso-themecolor:text1">WORK LOCATIONS/EXPECTIONS:

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minor-latin;color:black;mso-themecolor:text1">After orientation at the
Corporate facilities work is performed based on the following options approved
by management and with adherence to a signed telecommuting work agreement and
Patient Financial Services Remote Access Policy and Procedure..

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minor-latin;color:black;mso-themecolor:text1">� Full
time schedule worked in office

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minor-latin;color:black;mso-themecolor:text1">� Full
time schedule worked in a dedicated space in the home

mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">� Part
time schedule in office and in a dedicated space within the home

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mso-ascii-theme-font:minor-latin;mso-hansi-theme-font:minor-latin;mso-bidi-theme-font:
minor-latin;color:black;mso-themecolor:text1">Schedules must be approved in
advance by management who will allow for flexibility that does not interfere
with the ability to accomplish all job functions within the said schedule. Staff are required to participate in
scheduled meetings and be available to management throughout their scheduled
hours. Staff must be signed into
Microsoft Teams during their entire shift and communicate with Supervisor as directed.

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Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

BASIC KNOWLEDGE:

Must have current licensure to
practice as a Registered Nurse in the State of Rhode Island. Bachelor's Degree in Nursing Health Science
or Health Business required Master's Degree preferred.

EXPERIENCE:

Three years or more of relevant
recent clinical and/or administrative experience in medical/surgical nursing;
two years of which must be related to utilization review activities
demonstrating organizational skills and ability to make sound clinical judgment.

Working knowledge of level of
care criteria is required. Knowledge of
state and federal regulations is desirable.

WORK ENVIRONMENT AND PHYSICAL
REQUIREMENTS:

Work is performed in general
office environment with some exposure to patient care areas when meeting with
physicians managers etc. or to review other records not readily available.

INDEPENDENT ACTION:

Performs independently within the
department�s policies and procedures. Refers specific complex problems to the supervisor when clarification of
the departmental policies and procedures are required.

SUPERVISORY RESPONSIBILITY:

None.