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Appeals AND Grievance Nurse Registered Nurse II PRN

3 months ago

Houston, United States CHRISTUS Health Full time
  • 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.
  • Communicates with the CMO/VPMA regarding appeals and obtain signature for appeals
  • Knowledgeable of InterQual and Milliman Care Guidelines (MCG) medical necessity criteria
  • Interqual and/or MCG certification preferred.