![Hackensack Meridian Health](https://doximity-res.cloudinary.com/image/upload/c_pad,f_auto,h_160,q_auto,w_160/v1499117729/qhr2rf8bleyzdyxsu8lm.png)
Appeal Nurse Specialist
1 week ago
Overview:
Our team members are the heart of what makes us better.
At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed.
Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.
The Appeal Nurse Specialist will be responsible for the timely review and submission of appeals for denied managed care inpatient and/or outpatient claims to insurance companies for reconsideration of denials and/or level of care change determinations.
Gathers and evaluates the information for appeals of Managed Care audits, clinical and technical denials by utilizing various Epic and legacy systems for Hackensack Meridian Health (HMH) hospitals.
Responsible for following all regulatory compliance requirements. Serves as a functional expert and liaison to other departments within the hospital system (i.e:
patient access, patient accounting, and Care Management).
Responsibilities:
A day in the life of a Appeal Nurse Specialist at Hackensack Meridian Health includes:
Reviews all retroactive denials in the Epic work queues to assess and evaluate for appropriateness of appeal and identify cases that might require an action other than an appeal letter using department guidelines for such cases (i.
e:
Timely Filing Limits, etc.) and mitigate those cases as per Department Guidelines.
Utilizes the evidence-based guidelines in the appeal process.
Apply knowledge of MCG Criteria and/or other applicable guidelines for medical necessity, setting and level of care and concurrent denial management.
Educates, trains, and serves as a resource person for the Care Management team, medical staff, residents, and other hospital staff on current utilization review methodologies, requirements and criteria.
Communicate with the Physician Advisor in a timely and professional manner any instances where an alternate level of care billing might be appropriate and accurately document his response as per protocol and communicate this information with appropriate departments such as Access Services, Patient Accounting and Care Management.
Collaborates with third party payers and clinical service lines as needed and provides clinical information as appropriate.Complete first level Appeals utilizing pertinent clinical information, professional standards and clinical guidelines.
Accountable for consistency and accuracy between the department work queue and department worksheet for designated accounts per group assignments on a daily basis.
Monitors retro denials to ensure resolution within required time frames and logging of action e.g. no appeal, appeal level and final decision with revenue impact
Reviews thoroughly all medical records in multiple systems to ensure a complete understanding of the reason for denial in order to proceed in the initiation of a written appeal to the designated Insurance company.
May be required to Facilitates payer audit requests, i.e. Equiclaim, RAC, etc. for medical necessity denials.
Participate in all Team Huddles and any other department meetings as scheduled.
Adheres to HMH Organizational competencies and standards of behavior.
Other duties and/or projects as assigned.
Qualifications:
Education, Knowledge, Skills and
Abilities Required:
Associate degree in nursing from an accredited School of Nursing.
Minimum of three years of acute care nursing experience with knowledge of standard Utilization Management criteria, broad-based clinical knowledge, familiarity with critical pathways, current regulatory requirements, and legislation for third-party payers and payer practice patterns.
Demonstrates customer-focused and interpersonal skills to interact effectively with physicians, health team members, community agencies, insurers, and clients with diverse opinions, values, and religious and cultural needs.
Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.
Education, Knowledge, Skills and
Abilities Preferred:
Bachelor's degree in nursing (BSN).
Experience working in an acute health setting.
Minimum of 1 year of case management or equivalent experience.
Knowledge of Milliman Care Guidelines or Interqual.
Licenses and Certifications Required:
NJ State Professional Registered Nurse License.
Licenses and Certifications Preferred:
Certification in Case Management.
-
Appeal Nurse Specialist
3 weeks ago
Hackensack, New Jersey, United States Hackensack Meridian Health Full timeOverview Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one...
-
Appeal Nurse Specialist
2 months ago
Hackensack, New Jersey, United States Hackensack Meridian Health Full timeOverview Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one...
-
Expedited Appeals Specialist
4 weeks ago
New York, United States EmblemHealth Full timeSummary We are seeking a dynamic Expedited Appeals Specialist responsible for processing expedited appeals: those that are complex, require multiple hand-offs, and tend to have extremely tight deadlines. This individual will ensure accuracy and compliance within the constraints of extremely quick turnaround times. The Expedited Appeals Specialist will also...
-
Appeals Nurse
17 hours ago
New York, United States Centene Corporation Full timeYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This position requires NY RN Licensure. Daily responsibilities include...
-
Appeals Specialist
2 months ago
New York, United States OMG Technology Full time**Appeals Specialist - I (Remote - EST or PST)** The schedule will be **Monday to Friday 8 am-5 pm** local time**.** **Position Summary**: Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and providers (or authorized representatives) in accordance with the standards and requirements established...
-
Clinical Review Clinician
1 month ago
New York, United States Centene Corporation Full timeYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must have a New York State clinical license. Position Purpose: Performs...
-
Clinical Review Clinician
3 weeks ago
New York, United States Centene Corporation Full timeYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must have a New York State clinical license. Position Purpose: Performs...
-
Remote Governmental Audit and Appeal Lead
2 weeks ago
New Haven, United States Yale New Haven Health Full timeOverview: To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. Responsible for the general coordination of Governmental...
-
Claims Resolution Specialist
2 months ago
Jersey City, United States Caduceus Inc Full timeJob DescriptionJob DescriptionOverview: Demonstrate competency as a claims resolution specialist for a large-scale multi-specialty/multi-site healthcare organizations in the U.S.Perform claims resolution or medical billing and appeals or claims denials in Athena within the last two years.Conduct AR Follow-up both on front end scrubs and back end denials...
-
Claims Resolution Specialist
3 weeks ago
Jersey City, United States Caduceus Inc Full timeJob DescriptionJob DescriptionOverview: Demonstrate competency as a claims resolution specialist for a large-scale multi-specialty/multi-site healthcare organizations in the U.S.Perform claims resolution or medical billing and appeals or claims denials in Athena within the last two years.Conduct AR Follow-up both on front end scrubs and back end denials...
-
Start Up Specialist
1 week ago
Hackensack, New Jersey, United States Hackensack Meridian Health Full timeOverview:Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one...
-
Human Resources Specialist
2 weeks ago
New Orleans, United States Fifth Circuit Court of Appeals Full timeMain content Job Details for Human Resources Specialist Court Name/Organization: Fifth Circuit Court of Appeals Overview of the Position: The Clerk’s Office for the Fifth Circuit Court of Appeals in New Orleans is now accepting applications for the position of Human Resources Specialist. The incumbent provides administrative and technical support for...
-
OP Clinical Denial Specialist
2 months ago
New Haven, United States Yale-New Haven Health Full timeOverview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. The OP Clinical Denial Specialist supports the...
-
OP Clinical Denial Specialist
3 weeks ago
New Haven, United States Yale-New Haven Health Full timeOverview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. The OP Clinical Denial Specialist supports the...
-
Cyber Security Specialist
2 months ago
New Orleans, United States Fifth Circuit Court of Appeals Full timeMain content Job Details for Cyber Security Specialist Court Name/Organization: Fifth Circuit Court of Appeals Overview of the Position: The Office of the Circuit Executive for the Fifth Circuit is accepting applications for a Cyber Security Specialist. The Fifth Circuit is composed of the federal courts and federal public defender organizations in...
-
OP Clinical Denial Specialist
2 weeks ago
New Haven, United States Yale New Haven Health Full timeOverview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. The OP Clinical Denial Specialist supports the...
-
Human Resources Specialist
1 week ago
New Orleans, United States United States Courts Full timeCourt Name/Organization: Fifth Circuit Court of Appeals Overview of the Position: The Clerk’s Office for the Fifth Circuit Court of Appeals in New Orleans is now accepting applications for the position of Human Resources Specialist. The incumbent provides administrative and technical support for a full range of human resources services that includes, but...
-
Clinical Nurse Specialist
1 week ago
New Jersey, United States Hackensack Meridian Health Full timeAt Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. We invite you to listen to a...
-
Clinical Nurse Specialist
1 week ago
New Jersey, United States Hackensack Meridian Health Full timeOur team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another...
-
Presentation Specialist with Banking domain
1 month ago
Jersey City, United States VDart Inc Full timeJob DescriptionJob Description• PowerPoint Specialists who can collaborate with internal with business community and internal teams to provide creative support to key creative and marketing projects, whether for an internal (new sales plan or product launch) or external (product demo, sales presentation) team, and to create...