Registered Nurse Appeals Analyst

REMOTE POSITION!!!

MUST HAVE HOME HEALTH & HOSPICE EXPERIENCE

JOB SUMMARY:

TheAppeals Analystperforms medical record reviews todeterminethe quality of careidentifiesquality issuesand assures compliance with medical record standards and regulatorymandatesasrelated to billing compliance.The incumbent analyzessubmittedclaims and/or claims to besubmittedas well as medical records todeterminebenefit coverage for medical services under review.This position educates providers on all aspects ofmedical record criteriatodeterminebenefit coverage for medical services. This position prepares written documents and/or reports of completed medical review determinations andsubmitsrecords to the payer as requested.

JOB REQUIREMENTS:

• EDUCATION:Must be a graduatefrom anaccreditednursingschool.ABachelors Degreein Nursingis preferred.

• EXPERIENCE:Minimum three (3) years of experience as a registered nursein a home health and/or hospiceclinical care settingis. Prior functional working experience in medical records review arena (Utilization Review Case Management and knowledge ofappropriate billingand coding guidelines) is.

• CERTIFICATION/LICENSURE:CurrentLicense as a Registered Nurseis required.

• SKILLS:

• Interpersonal skills and ability to manage workload and meet deadlines

• Demonstratedprofessional oral and written communication skills

• Demonstratedstrong organizational skills as well as autonomy with tasks assigned

• Demonstratedability to think critically and adapt to changes

• Excellent analyticalproblem solving andnegotiationskills

• Ability tocomprehendmedical policy and criteria to clearly articulate health information

• Demonstratedongoing understanding of current Medicare Medicaid and third-party regulations as changes occur

• Demonstratedknowledge in all levels of home health hospice palliative and home medical equipment practices

• Demonstratedproficiencyin use ofMicrosoft Office Suite (Excel Microsoft Word Power Point Outlook)

• TRANSPORTATION:Not applicable.

• TRAVEL:Not applicable.

• HEALTH STATUS: Meets all applicable agency policies and procedures related to health screening and requiredtesting.

KEY ACCOUNTABILITIES:

• Ensures that all activities performed align with the vision of Elara Carings board of directors executive team and the leadership of theComplianceteam.

• Promotes compliance with all regulatory standards through review of medical records.

• Maintains productivity quality and accuracy targets set by the Governmental Review Manager.

• Participates in Administrative Law Judgehearings as the company expert.

• • Educates providers on all aspects of medical review criteria.

  • Participates in the appeals process for claims denied by the government or other payers as necessary.

  • Collectsappropriate medicalrecords reviewsthe documentationfor validity andsubmitsthe requested documents for pre-claim reviews ADR requests and/or appeals.

  • Collaborates with providersto adhere to clinical standards of careto ensure appropriateoutcome.

  • Practices andadheres to departmental state and national guidelines.

  • Communicates with agencies related to documentation needsin a timely mannerandfollowsup with agency leadership as needed.

  • Conducts audits as needed to ensuredocumentationadequacy.

  • Provides education related to audit trends and denials.

  • Communicates significant findings problems and changes related to compliance with documentation standards to the director and other personnel involved with patient care.

  • Identifiesand communicates toGovernmental Review Managerand other supervisorypersonnelvisit documentation that lacks adequate content to support billing guidelines.

  • Participates in the development of strategies/education to prevent loss of revenue during recovery audits.

  • Assistswithdevelopmentof staff education tools/guides to promoteappropriate clinicaldocumentation and utilization.

  • Writes business letters and reports to explain determinations and decisions to a variety of audiences including but not limited to governmental payers private insurance providers and administrative law judges.

  • Participates in all levels of appeal using regulatory guidance and critical thinking to navigate appeals compliantly.

  • Promotes coordinates and evaluates operational Systems to enhance operations and promote efficiencies.

  • Provides leadership to team and support staff inidentifyingagency/client needs and opportunities for improvement.

  • Promotes Elara Carings philosophy missionstatementand administrative policies to ensure quality of care.

  • Maintains patient and staff privacy and confidentialitypursuant toHIPAAPrivacy Final Rule.

  • Performs other duties/projects as assigned.

  PHYSICAL AND ENVIRONMENTAL DEMANDS:

  • Mentallydemanding high stress environment

  • Sit stand bend lift and move intermittently and be able to lift at least 25lbs.

  • Move equipment and supplies necessary for job functions

  • Read speak and write Englishin order tofulfill job functions in an understandable way

  • See/hear or use prosthetics that enable accomplishment of job

  • Meet the health requirements of the agency

  • Possible exposureto infectious and communicable diseases chemicals and repetitive motions

  • Abide by all occupational safety and bloodborne pathogen protocol to minimize illness and/or injury

  • Complete required workdaily

  • Cope with work involving ill disabled and dying patients