Rn Special Clinical Appeals

In this role you will be responsible for: This position is accountable for conducting a comprehensive analytic review of clinical documentation, collaborating with Care Management Medical Director to complete an appropriate appeal, and documenting the appeals process for denied claims denied due to reasons including, but not limited to clinical documentation/support for DRG assignment, inpatient services, medical necessity. The individual works third-party payer including responding to inquiries, complaints, and other correspondence. Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied. . Utilize pre-existing criteria and interQual and clinical evidence to develop sound and well-supported appeal arguments. File medical necessity and level of care appeals using InterQual and CMS guidelines . Collaborate with Medical Director on preparing convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments, for an Administrative Law Judge hearing and participate in hearings by providing testimony, if and when necessary. . Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Maintain documentation regarding all payor resources regarding denials and appeals processes.. Track and manage outcome of written appeals . Prepare feedback to case managers regarding clinical documentation and denial trends and participate in monthly meetings.. Ensure compliance with HIPAA regulations, to include confidentiality, as required.. Observe professional ethics in maintaining confidential information acquired concerning the personal, financial, medical or employment status of patients (and their families) provided services by the hospital.. Other duties as assigned. .
Qualifications
If you possess the following qualifications, please apply immediately: Extensive clinical knowledge and understanding of pathophysiology demonstrated by experience working in an acute care hospital setting.. Excellent written and verbal communication skills with the ability to write and speak concisely and professionally when communicating with providers. Self-motivated with strong critical thinking and problem solving skills.. Must possess the ability to create and deliver clinical education programs on CDI for the medical and hospital staff. . Working knowledge of PC applications required, including Microsoft Windows Application (Word, Excel, and Powerpoint). . Knowledge of ICD 10 CM/PCS coding classification system and MS/APR DRG is preferred. . RN with acute care experience in Critical Care or Emergency Department within the last 5 years required or Care Management experience in the last 5 years with prior RN experience in Critical Care or Emergency Department OR minimum of 1 year previous CDI experience.
Conditions of Employment
Since this position will require the selected candidate to engage in regular contact with children in the form of care, guidance, supervision or training, you will be required to meet the requirements of the Child Protective Services Act, including the Pennsylvania State Police criminal background check, the Pennsylvania Department of Welfare child abuse criminal background clearance, and an FBI finger print based federal criminal records check. The selected candidate will not be allowed to commence working until all three (3) are completed satisfactorily.
Conditions of Employment
Covid Vaccination is a requirement for employment at Jefferson for employees working at Jefferson's clinical entities or at the University. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date if you are offered employment, unless you request and receive an approved medical or religious exemption from Jefferson.
Closing Statement
Jefferson includes Thomas Jefferson University and Jefferson Health, a dynamic university and health system with broad reach across the Delaware Valley. Jefferson is the second largest employer in Philadelphia and the largest health system in Philadelphia based on total licensed beds.
Through the merger of Thomas Jefferson University and Philadelphia University in 2017, our University includes ten colleges and four schools. We are an NCAA Division II university and an R2 national doctoral university offering undergraduate and graduate-level programs that provide students with a forward-thinking education in architecture, business, design, engineering, fashion and textiles, health, medicine and social science.
Jefferson Health, the clinical arm of Thomas Jefferson University, has grown from a three-hospital academic health center in 2015, to an 18-hospital health system through mergers and combinations that include hospitals at Abington Health, Aria Health, Kennedy Health, Magee Rehabilitation and Einstein Healthcare Network. We have over 50 outpatient and urgent care centers; ten Magnet®-designated hospitals (recognized by the ANCC for nursing excellence); the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in the country and one of only two in the region); and one of the largest faculty-based telehealth networks in the country. In 2021, Jefferson Health became the sole owner of HealthPartners Plan, a not-for-profit health maintenance organization in Southeastern Pennsylvania. We are the first health system regionally to create an aligned payer-provider partnership.
Jefferson's mission, vision and values create an organization that attracts the best and the brightest students, faculty, staff, and healthcare professionals, as well as the most visionary leaders to drive exceptional results.

• OUR MISSION: We improve lives.
• OUR VISION: Reimagining health, education and discovery to create unparalleled value
• OUR VALUES: Put People First, Be Bold & Think Differently and Do the Right Thing

As an employer, Jefferson maintains a commitment to provide equal access to employment. Jefferson values diversity and encourages applications from women, members of minority groups, LGBTQ individuals, disabled individuals, and veterans.
Par Reference Code
93354