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Insurance Services Appeals Nurse
Acclara Solutions

Location: Remote
Work Setting: Other
Job Function:
Other
Job Type:
Full-Time

Job Description

Insurance Services: Clinical Appeal Nurse

The Clinical Appeals RN performs clinical appeals and/or reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase in accordance with internal policy and procedures, as well as regulatory guidelines and timeframes. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, determination that a treatment investigational/experimental, and/or that the treatment rendered is not Medically necessary. Additionally, this position will actively manage, maintain and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to the Leadership team.

EDUCATION & WORK EXPERIENCE:

• Current issued RN license required

• 3-5 years of experience as a clinical nurse in an acute care setting experience is required

• Experience in case management, discharge planning, and/or utilization review is preferred.

REQUIRED KNOWLEDGE & SKILLS:

  • Knowledge of managed care and regulatory and payer requirements for reimbursement and reason(s) for denials by auditors.
  • Medical Terminology, coding knowledge of HCPCS, CPT and ICD10.
  • Basic tying skills, advanced ability to perform internet-based research
  • Ability to proficiently read, understand, and abstract information from handwritten and electronic patient medical records are essential prerequisites.
  • Working knowledge of Microsoft Excel, Microsoft Word and other Microsoft applications.
  • Excellent writing skills.
  • Knowledge in areas such as Milliman Care Guidelines, Hayes & InterQual Criteria as well as knowledge of third-party payer regulations related to utilization and quality review is also preferred.
  • Knowledge of EPIC Patient Accounting system is a plus
  • Experience and knowledge of managed care contracts, account receivables and revenue cycle functions.
  • Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry based standards.
  • Computer literate with fluency Microsoft – Word & Excel
  • Ability to maintain confidentiality of sensitive information
  • Ability to manage multiple tasks with ease and efficiency
  • Self-starter with a willingness to try new ideas
  • Ability to work independently and be result oriented

CORE RESPONSIBILITIES & FUNCTIONS:

Core responsibilities include but are not limited to the items listed below:

  • Responsible for managing medical denials by conducting a comprehensive review of clinical documentation.
  • Write compelling arguments based on the clinical documentation and the medical policies of the pay or and submit the appeal in a timely manner.
  • The primary objective is to overturn the denial and maximizing reimbursement based upon services delivered and ensuring that the claim is paid/settled

  • Collect relevant medical information and apply the appropriate evidence-based guidelines and medical policy for denied services associated with appeals/grievances
  • Follow documentation guidelines for clear and concise decision-making within our utilization review tracking platform
  • Gather, investigate, and respond re: member and provider appeals/grievances both verbally and in writing
  • Working familiarity with applicable regulatory and accreditation requirements

Our Culture

  • We work hard to make Acclara a wonderful place to work. Our people are our greatest assets, and we encourage employees to grow and develop, assuming greater responsibilities and leadership roles.
  • Put the Patient First: The philosophy behind our approach is simple: drive revenue by putting the patient first.While our philosophy is simple, the key to our success is in the details.
  • Hard Work, Diligence to Every Detail, and Passionate Service

WORK ENVIRONMENT:

  • Physical Demands: While performing the duties of this job, the employee is occasionally required to walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; balance; stoop; talk or hear. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
  • Work Environment: The noise level in the work environment is usually moderate
  • Work Hours: Salaried position which often requires exceeding the normal 40 hours per week
  • Travel: Requires travel to and from client sites on a regular basis

Apply Online: https://acclara.com/careers/

Posted: September 2, 2021 at 9:34 AM
Post ID: 62735

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