The Clinical Appeals RN is responsible for the identification and resolution of technical and/or clinical based denials through appeals. The Appeals Nurse will work with Revenue Cycle staff, case management, clinical departments, practices, and insurance payers (government & commercial) to identify the source of denials and develop processes to eliminate and/or minimize denials and rejections to improve cash flow. The Appeals Nurse works denied and underpaid accounts to obtain full reimbursement for services provided and identify the underlying root cause. The Appeals Nurse will develop recommendations and education plans to prevent future denials and will routinely communicate findings and activities to stakeholders. An Appeals Nurse will serve as the central point person for recovery and audit activities as they relate to clinical denials and overpayments. The Appeals Nurse will be responsible for ensuring clinical appeal deadlines are met to maintain maximum opportunity for reimbursement retention.
Responsibilities
Principle Duties and Responsibilities – Essential Functions & Skills
Review technical and clinical denials for reconsideration and appeal on accounts.
Reviews medical records and criteria to determine the need for payer appeal.
Works in conjunction with physicians, case managers, and coders to obtain all necessary information for appeals.
Prepares and submits written appeals to insurance companies that detail the medical necessity and appropriateness of treatments provided.
Investigates insurance denials to identify and implement best course of action and coordinates with other departments as needed.
Retrieves, creates, and organizes data and activity on a daily, weekly, monthly basis for reports.
Communicates effectively both in written and oral format.
Keeps abreast of applicable federal and state regulatory guidelines and criteria. Stays current on trends related to medical necessity, DRG, and automated denials.
Documents all actions and outcomes of appeal efforts in an appropriate manner and system.
Works independently and displays initiative to identify clinical and technical denial patterns and recommends process improvements.
Coordinates with management to identify gaps and failure points within the revenue cycle or clinical documentation process that can mitigate future denials.
Build strong working relationships within the Revenue Cycle and other colleagues at all levels of the organization, as well as third parties to resolve issues as needed.
Serves as a central contact for recovery audit activities as they relate to clinical denials and audits. Responsible for meeting all deadlines related to these activities.
Presents a positive professional image. Demonstrates and displays excellent organizational and time management skills while paying close attention to detail.
Demonstrates flexibility to adjust workload as needed.
Other duties as assigned.
Qualifications
Education Requirements
Bachelor’s Degree Required, BSN preferred
Advanced degree preferred
Experience Requirements
- Minimum five (5) years’ experience in clinical denials, case management, or technical denial management.
- Medical terminology.
- Detail oriented, self-motivated, problem solver, and a team player.
- Ability to work independently as well as in a team environment.
- Ability to excel in a very fast-paced team environment.
- Excellent interpersonal skills & professional demeanor.
- Ability to effectively communicate research findings and recommendations.
Certification Requirements (must remain active throughout employment)
- RN