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Appeals AND Grievance Nurse Registered Nurse II PRN
3 months ago
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 appealsKnowledgeable of InterQual and Milliman Care Guidelines (MCG) medical necessity criteriaInterqual and/or MCG certification preferred.
