RN Clinical Review Appeals Specialist
RN Clinical Review Appeals Specialist
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Job Description
St. Lukes is proud of the skills experience and compassion of its employees. The employees of St. Lukes are our most valuable asset! Individually and together our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians nurses and other health care providers; and improve access to care in the communities we serve regardless of a patients ability to pay for health care.
The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records claims data and coding of all diagnosis and procedure codes to assure properly assigned MSDRG or APRDRG for the purpose of appealing proposed DRG and coding changes by insurance providers or their respective auditorsJOB DUTIES AND RESPONSIBILITIES:
- Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MSDRG/APRDRG accuracy based on denials or audit findings from government and commercial payers. Meet or exceed established benchmarks for productivity while maintaining quality.
- Identify and provide feedback including identification of trends to the Network Coding and CDMP Managers for education of the medical staff clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding assignment of documented medical care for appropriate reimbursement.
- Work with the physician advisor in review of patient medical records identified by RAC/MIC/QIO and other governmental or commercial payor auditors in retrospective reviews for DRG and documentation or codingrelated issues.
- Develop and apply appeal arguments and draft appeal letters to support and defend the codes assigned by the coding professionals and be able to refute the clinical validation or coding determination made by the government or commercial payors or their auditor representative.
- Facilitate clinical chart reviews to assist with supporting assigned diagnosis and/or procedures codes of medical conditions as documented in the patient medical record and identify clinical documentation improvement issues and through excellent communication with physicians coding and CDMP leadership Quality Dept. coordinators and other members of the health care team working independently and collaboratively to resolve such issues.
- Participate in Administrative Law Judge (ALJ) hearings and/or formal meetings with auditor or payor representatives in defense of coding appeals as needed.
- Maintain necessary audit/appeal activity documents including Excel spreadsheets EPIC Payor Audit Management tool Word Documents Outlook email/calendar and other workflow communication tools. Possess ability to evaluate reports from Epic PAMs or spreadsheets as needed for workflow or identification of trends. Assists in preparing reports regarding denials to include volumes number of appeals case resolution and impact on revenue and trending.
- Facilitates retrospective clinical record reviews for outpatient/CPT payor recommendations in collaboration with the OP Coding Supervisor or Network Coding Operations Director.
- Responsible for maintaining uptodate working knowledge of ICD10CM/PCS coding and MSDRG principles and AHA coding guidelines.
- Responsible to remain current on clinical criteria as it pertains to Nuance Clinical Documentation Management Program strategies for clinical documentation or current program in use for clinical documentation improvement program AHA Official Coding Guidelines for Coding and Reporting of diagnoses and procedures AHA Coding Clinic.
PHYSICAL AND SENSORY REQUIREMENTS:
Sitting standing and light arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting comfortable temperature and ventilation.
EDUCATION:
Registered Nurse required BSN preferred. Current license required..
TRAININGAND EXPERIENCE:
Minimum five 5 years RN/licensed provider experience in adult inpatient medicalsurgical or critical care with thorough understanding of disease processes knowledge of HIM field helpful with focus on MSDRG reimbursement AHA coding guidelines and compliance or direct Clinical Documentation Improvement experience. Previous audit experience preferred. Working knowledge of ICD10CM/PCS. Knowledge of reimbursement systems regulations and policies pertaining to documentation coding and as needed medical necessity. Previous experience with electronic patient medical record/EPIC and 3M encoding system preferred.
Please complete your application using your full legal name andcurrent home address. Be sure toincludeemployment history forthe past seven 7 years including your present employer. Additionally you areencouraged to upload a current resume including all work history education and/or certifications andlicenses if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Lukes!!
St. Lukes University Health Network is an Equal Opportunity Employer.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
