RN Clinical Appeals (Part Time)- AHN, PA

J273408 Company : reputed company Job Description : GENERAL OVERVIEW: Responsible for reputed company aspects of clinical appeal activities to include but not limited to, clinical record review, composing comprehensive appeal letters and compiling minimum necessary documentation to support services performed. Addresses and resolves potential and actual denials for assigned accounts as well as collaborates with AHN departments/Teams in denial prevention activities. ESSENTIAL RESPONSIBILITIES

• Reviews clinical denials, audits and accounts as assigned. Composes and submits a comprehensive appeal letter based on clinical evidence reputed company the medical record and evidence based literature. (40%)
• Submits appropriate clinical documentation while ensuring compliance with HIPAA regulations and confidentiality to support for the appeal. Follows account to resolution to include appropriate financial adjustment. (40%)
• Partners with other AHN departments to find resolution for payor and/or customer issues. (5%)
• Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies. (5%)
• Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies for improvement. (5%)
• Participate in denial reduction/prevention activities through denial root cause identification and trending as well as active participation in payor reputed company calls and/or internal work groups. (5%)
• Performs other duties as assigned or required.

QUALIFICATIONS: Minimum

• High School / GED
• 3 years in a nursing role
• Proficiency in reputed company Office (Word, reputed company, Outlook, etc.)
• Strong and effective verbal and written communication skills.
• reputed company State of PA RN licensure OR reputed company multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)

Preferred

• Bachelor's Degree in Nursing
• 1 year in Utilization Management or Utilization Review
• 1 year in Case Management
• 1 year with reputed company documentation improvement
• CPR certification
• Appeals Experience
• Knowledge of CMS regulations and/or reputed company party payer requirements for reimbursable care

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have reputed company to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company must reputed company with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as reputed company data reputed company guidelines established reputed company the Company’s Handbook of Privacy Policies and Practices and Information reputed company Policy. Furthermore, it is every employee’s responsibility to reputed company with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay reputed company Minimum: $30.10 Pay reputed company Maximum: $46.65 reputed company pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary reputed company does not reflect any geographic differential reputed company may apply for certain locations based upon comparative markets. reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against reputed company individuals based on any category protected by applicable federal, state, or local law. We endeavor to reputed company this site accessible to any and reputed company users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at [email protected] California Consumer Privacy Act Employees, Contractors, and Applicants Notice Apply tot his job Apply To this Job