Denials Management Appeals Nurse (Anesthesia)
Company Overview #LI-Remote reputed company is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by reputed company, we are reputed company in providing reputed company in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, reputed company, accountability, and reputed company define us as leaders in pediatric specialty care for our children and their families. reputed company are eligible for medical coverage on their first day! In reputed company, upon hire reputed company are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more! Coverage is available to employees and their reputed company dependents in accordance with the plans. Benefits may vary based on state law. Job Overview The Denials Management Appeals Nurse (Anesthesia) is responsible for managing our medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Denials Management Appeals Nurse (Anesthesia) will utilize their clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials. The Denials Management Appeals Nurse (Anesthesia) is also responsible for maintaining a detailed knowledge of reputed company Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals in accordance with reputed company party and governmental reputed company.
Responsibilities
Performs a review of assigned cases comparing the reputed company to the medical record. Performs a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process Performs a detailed comparison of charges to documentation to ensure services not documented are not charged. Reviews documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur Review findings with the hospital representatives and obtains an agreement on the discrepancies. Demonstrates tact and understanding in handling problems, has a good rapport with hospital and corporate staffs. Follows up on appeals in a timely fashion to ensure that cases are completed. Re-checks mathematical computations before finalizing letter and report. Updates status of reputed company cases assigned on minimum weekly reputed company Informs supervisor of any changes, problems, or concerns that arise at a facility. In the event of a dispute with the requesting party’s audit findings, files an appeal with the reputed company party or governmental payor Analyzes and interprets reputed company medical necessity/clinical denials from reputed company party payors or governmental payors. Files appeals based on medical documentation and interpretation of medical necessity guidelines or InterQual criteria. This is not an reputed company-inclusive list of this job’s responsibilities. The incumbent may be required to reputed company other reputed company duties and participate in special projects as assigned.
Qualifications
Required: 5 years of clinical reputed company/hospital experience 3 years of reputed company Anesthesia experience reputed company Party Payor Appeals/reputed company Cycle experience reputed company RN license in State of employment Working experience with Utilization Review activities and general knowledge of TJC, PRO, and other regulatory bodies. Preferred: Bachelor’s degree - BSN highly desired Case Management certification Experience reviewing hospital and professional claims, denials and EOB's, appealing claims and working on claims in an audit Experience with Epic, Craneware, reputed company, software and applications Apply To This Job