Clinical Appeals and Denials Nurse

The Clinical Appeals and Denials Nurse reviews, monitors and analyzes denials received from payors (Medicare, Commercial and Third Party) and coordinates with Revenue Cycle team to seek proper reimbursement for those services rendered. This position also ensures medical necessity and documentation related issues are reviewed and coordinated with departments and medical staff.

The coordination with Case Management on denials/reduced payments associated with Inpatient/Observation will be monitored and analyzed to ensure physicians remain compliant with proper documentation and level of care assignments.

Work Schedule

Flexible schedules to cover all shifts and weekends, as hospital needs demand.

Primary Duties

Audit and Appeal:

• Monitors insurance denials as by running appropriate reports and contacting third parties to resolve claims denied.
• Serves as liaison with third-party payers/agencies regarding appeals to ensure optimal reimbursement and any other billing/payment issues or questions are resolved.
• Develops recommendations to maintain efficient and effective processes.
• Identifies coding and clinical documentation issues and work to correct the errors in a timely manner.
• Identifies problem accounts and escalates as appropriate.
• Updates patient account record to identify actions taken on the account.
• Evaluates requests to acquire research material utilized as requested and retain in an organized manner
• Gather research information utilizing appropriate research tools available and analyze. Report in meaningful and comprehensive reports.
• Ability to write clearly and concisely, handle necessary technical vocabulary and organize difficult or complex information in an understandable and efficient manner.
• Prepares accurate statistical/other reports as directed.
• Complete and submit departmental reports accurately and timely.
• Maintain up to date documentation on system and charge master changes.
• Continuously analyzes hospital charge master for accuracy and appropriateness.
• Leads/Assists departments with development of their charge master items. Communicates changes as needed.
• Validates pricing and cost of submitted charge master requests in conjunction with Finance. Validates proposed changes and the affect of such changes on other systems in the organization
• Tracks and trends ancillary charging errors monthly. Works with departments to identify resolution.
• Establish and maintain essential records and files. Gathers, assembles, and arranges extensive contractual data and information for easy retrieval and reference.
• Responsible for favorable resolution of third party payment denials, adverse determinations, medical necessity denials, payment discrepancies and contract misinterpretations.
• Review, distribute and analyze the impact of all new regulations and requirements from payors. Provide payor specific billing requirements to all departments and assures appropriate actions are in place to meet requirements.
• Performs other duties as assigned.
• Education: Graduate of an accredited program of nursing required, LPN; BSN preferred.
• Licensure/Certification: Current state Registered Nurse license or license from a state within the Nursing Compact required.
• Experience: Minimum of 3 years clinical experience in a clinical setting preferably hospital inpatient and outpatient department, cardiovascular nursing preferred. Two years of case management experience preferred. Charge master for acute care healthcare. CPT/HCPC coding knowledge. Medicare billing guidelines preferred. One year experience in collection, analysis, and interpretation of data within the context of conducting statistical, organizational and administrative studies preferred.