UM Appeals Nurse
UM Appeals Nurse
Employer Active
Job Alert
You will be updated with latest job alerts via email
Share
Job Alert
You will be updated with latest job alerts via email
Job Description
SUMMARY
Employee is expected to cheerfully and enthusiastically carry out tasks and responsibilities of the job including but not limited to high quality professional patient care thorough and accurate documentation a willingness to work closely with physicians administrators coworkers and supervisors. Prompt assistance to other units/ departments is expected as well as prompt assistance within the employees own unit/ department. By following the guidelines outlined in this job description high quality patient care will be assured and the continued success of Curative.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Interacts with providers facilities and their staff regarding appeals and complaints and ensuring all assigned work is completed by the end of each workday.
Review denied medical claims and services to determine the validity of the denial based on clinical guidelines medical necessity and payer policies
Draft comprehensive appeal letters and clinical justifications to support overturning denied claims ensuring accuracy compliance and timeliness
Analyze patient medical records treatment plans and diagnostic results to assess the appropriateness and necessity of care
Communicate with physicians healthcare providers and insurance representatives to clarify medical information and support the appeals process
Ensure all appeals reviews and communications are documented accurately in accordance with regulatory and organizational policies
Stay up-to-date with insurance payer guidelines clinical protocols and regulatory requirements (e.g. CMS NCQA URAC)
Monitor and report on appeal status and success rates; identify trends and recommend process improvements to reduce denials
Provide clinical insight to case managers utilization review staff and billing departments to prevent future denials
Protect patient confidentiality and ensure all appeal activities follow HIPAA and other privacy laws
Contribute to initiatives aimed at enhancing the efficiency and effectiveness of the appeals process
Participates in special projects as required
Researches complex cases as needed under the direction of the Manager or Medical Director
Performs other duties as assigned not limited to but including availability to work occasional weekends depending on business needs
QUALIFICATIONS
To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions:
Current knowledge of services provided across the continuum of care that involve multiple systems addressing the ongoing needs of the patient
Knowledge of discharge planning
Familiarity with community agencies and with how to make appropriate referrals to them
Knowledge of different hospital reimbursement methodologies and concurrent review criteria
Excellent verbal and written communication skills
Computer skills
Ability to identify ways to decrease hospital days in a medically safe and responsible manner
CERTIFICATES/LICENSES EDUCATION and EXPERIENCE
Unencumbered active RN license in state of primary residence
Associate or Bachelor Degree in Professional Nursing
At least four years of clinical experience in hospital nursing such as Critical Care/ER/Med Surg/Home Health. Two years of appeals and utilization/case management (managed care preferred). One to two years of concurrent review or retrospective review with an emphasis on discharge planning.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job the employee is regularly required to sit; use hands to handle or feel; talk; and hear.
The employee is frequently required to reach with hands and arms.
Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and ability to adjust focus.
The noise level in the work environment is usually: Mild moderate Severe
For this position the percentage of expected Travel is less than 5 % of the time
Required Experience:
IC
Employment Type
Full-Time
