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Appeals AND Grievance Nurse Registered Nurse II

3 months ago

Tyler, Texas, United States Christus Health Full time

Summary:

Responsible for the management and communication ofdenials/appeals received from third party payers, managed carecompanies, and/or government entities/auditors related to medicalnecessity and/or level of care. This associate will be a liaisonand point of contact for clinical denials and appeal inquiries. TheClinical Appeals Nurse will review each case identified/referredfor appeal based on Milliman Care Guidelines (MCG), InterQual,and/or other relevant guidelines, determined the viability of theappeal, and manage the appeal process. The Clinical Appeals Nurseis responsible for appealing all inappropriate denials through allpossible levels of the appeal process. The RN Clinical AppealsNurse will actively manage, maintain and communicate denial/appealactivity to appropriate stakeholders, and report suspected oremerging trends related to payer denials. Working with CaseManagement leadership, this individual will orchestrate educationand other performance improvement initiatives to impact clinicalquality, improve efficiency and mitigate lost revenue related tomedical necessity denials. Key Performance and trends related todenials/appeals will be reported to the facility.

Responsibilities:

  • Focuses on the review and analysis ofgovernmental denial rationales and provides appropriate medicalnecessity appeal services
  • Review governmentalcontractors response letter in comparison to the medicalrecords
  • Communicates with facility regardingmissing or insufficient medicaldocumentation
  • Review medical documentation foradherence to Medicare guidelines relating to inpatient services (orother Medicare issues) and draft appropriate appeal letters basedupon professional clinical opinion as to the medical necessity ofthe services provided
  • Research issues usingfederal or law, federal regulations, and relevant CMS policiesCommunicates with members of the healthcare team identifying rootcauses for potential denials
  • Communicates withthe CMO/VPMA regarding appeals and obtain signature forappeals
  • Assures all discussions and appeals arefiled timely
  • Completes data entry in the Denialdatabase for tracking, trends, and analysis

Requirements:

  • Associate's Degree inNursing
  • RN License in state of employment orcompact

Work Type:

Full Time

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