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RN Clinical Appeals - PRN

Company: CHRISTUS Health
Location: Tyler
Posted on: May 4, 2021

Job Description:

Job Description Description Summary: Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility.The RN Clinical Appeals Nurse will perform duties aimed at denials prevention and billing compliance. Requirements: * TX RN License * Graduate of accredited school of nursing, BSN preferred * 2 to 4 years experience in Case Management or denial and appeals experience strongly preferred * Experience with managed care, governmental and/or RAC appeals strongly preferred * Understanding of Medicare, Medicaid and third party reimbursement methodologies * Knowledge of InterQual and Milliman Care Guidelines (MCG) medical necessity criteria * Interqual, MCG or Case Management certification preferred Work Type: Per Diem As Needed

Keywords: CHRISTUS Health, Tyler , RN Clinical Appeals - PRN, Healthcare , Tyler, Texas

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