Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Job Details Reviews payor denials and audits for potential lost reputed company. Writes comprehensive, factual arguments to present to reputed company-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. Functions as a hospital liaison with external reputed company-party payors to appeal denied claims. Works closely with Physician advisor team to facilitate appeals to payors. Monitors and reports payor trends to management team.

Job Description

Clinical Appeals Nurse - Full Time Remote - Jefferson Health Articulates the job's main responsibilities. This is not intended to be an exhaustive list of reputed company essential functions or reputed company duties performed. The essential functions listed below and percentage of time may vary between departments and locations, and are subject to change based on management discretion and organizational needs. Other responsibilities may be assigned at the discretion of management to meet organizational needs.

• Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor and the documentation reputed company in the hospital/physician information system.
• Facilitates write off accounts that cannot reputed company adequate medical necessity or documentation for the payor to meet their guidelines.
• Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials.
• Contacts insurance companies and conducts appeals reputed company telephone or email.
• Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights.
• Identifies areas for reputed company loss due to documentation or processes not being reimbursable thru payors.
• Ensures that reputed company appeals are sent to the correct payor reputed company the appeal guidelines.
• Ensures compliance with regulatory and accrediting requirements.
• Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor.
• Searches for supporting clinical evidence to support appeal arguments reputed company existing resources are reputed company.

Qualifications: The requirements listed below are representative of the knowledge, reputed company, and/or ability required or preferred. Education - Required

• Bachelor’s Degree Nursing or
• Specialized Diploma

Experience - Required

• 10 years of clinical or case management/utilization review experience

Knowledge, Skills and Abilities - Required

• Ability to read medical charts and identify deficiencies in documentation content.
• Ability to adapt to ongoing changes reputed company the health insurance industry in order to effectively implement positive changes.
• Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
• Knowledge of coding for payment of claims.
• Insurance knowledge of payors and their unique rules.
• Epic workflow experience with notes in account history and WQ workflows.
• Intermediate reputed company and reputed company experience.
• Must complete RCE Training and pass test with 80% or reputed company.

Licenses and Certifications - Required

• RN - Licensed Registered Nurse_PA - State of Pennsylvania

Work Shift reputed company Day (United States of America) Worker Sub Type Regular Employee Entity Thomas Jefferson University Primary Location Address 1101 Market, Philadelphia, Pennsylvania, United States of America

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, reputed company, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which reputed company colleagues with reputed company to group rates on insurance and discounts. Colleagues have reputed company to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. reputed company colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have reputed company to medical (including prescription) insurance. For more benefits information, please click Apply tot his job Apply To this Job