Appeals and Grievance Nurse Registered Nurse II PRN

7 days ago


Houston, United States Christus Health Full time
Job 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. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. 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.

Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services
Review governmental contractors response letter in comparison to the medical records
Communicates with facility regarding missing or insufficient medical documentation
Review medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided
Research issues using federal or law, federal regulations, and relevant CMS policies
Communicates with members of the healthcare team identifying root causes for potential denials.
Communicates with the CMO/VPMA regarding appeals and obtain signature for appeals
Assures all discussions and appeals are filed timely
Completes data entry in the Denial database for tracking, trends, and analysis

Requirements:

Graduate of an accredited School of Nursing with a Bachelor’s degree in nursing or health related field.
Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task
Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff).
Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomes
Assertive and diplomatic communication, proven ability to function on a multidisciplinary team.
Excellent organizational skills including effective time management, priority setting and process improvement.
Two to four years of Utilization Review/Case Management experience.
Two-three years’ experience in the denial and appeal process.
Experience with managed care, governmental and/or RAC appeals strongly preferred.
Knowledgeable of InterQual and Milliman Care Guidelines (MCG) medical necessity criteria
Understanding of Medicare, Medicaid and third party reimbursement methodologies.
Computer experience in Microsoft Office (Word and Excel).
Current RN Nursing license
Interqual and/or MCG certification preferred. Case Management certification preferred

Work Type:

Per Diem As Needed
Req. No

133545

Job Title

Appeals and Grievance Nurse Registered Nurse II PRN

Market

CHRISTUS System Office

Category

Revenue Cycle

Facility

CHRISTUS Corp Houston Office and TLRA Revenue Cycle

Address

2900 North Loop West
Houston, TX 77092
US

Type

PRN

  • Houston, United States Christus Health Full time

    Job DescriptionYou could be just the right applicant for this job Read all associated information and make sure to apply.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. This associate...

  • Appeals and Grievance Nurse Registered Nurse II PRN

    Found in: Talent US C2 - 1 week ago


    Houston, United States CHRISTUS Corp Houston Office and TLRA Revenue Cycle Full time

    Job 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. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical...


  • Houston, United States Christus Health Full time

    DescriptionSummary: 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. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse...

  • Appeals AND Grievance Nurse Registered Nurse II PRN

    Found in: Careerbuilder One Red US C2 - 2 weeks ago


    Houston, TX, United States Christus Health Full time

    DescriptionSummary: 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. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse...


  • Houston, United States Apex Health Solutions Full time

    Job DescriptionJob DescriptionJob Title: Appeals & Grievances CoordinatorDepartment: Appeals and GrievancesSupervisor: Manager, Appeals & GrievancesFLSA Status: NonexemptSummaryThe Appeals and Grievances coordinator position is focused on the processing of customer and provider Medicare and Commercial appeals and grievances. This associate may screen...


  • Houston, United States Harris Health System Full time

    Harris Health System is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management...

  • Registered Nurse

    1 week ago


    Houston, United States FCM Group, LLC dba Nurse Next Door - Pearland & Kingwood Full time

    Job DescriptionJob DescriptionBenefits/PerksFlexible SchedulingCompetitive CompensationCareers AdvancementJob SummaryWe are seeking a Registered Nurse to join our team. In this role, you will primarily be creating and managing a plan of care for individual patients. You are a Registered Nurse (RN) who operates with great attention to detail and a big heart....

  • Nurse Clinician II

    Found in: Talent US C2 - 1 week ago


    Houston, United States Harris Health Full time

    Job SummaryThe Nurse Clinician II (NCII) has knowledge and skills necessary to meet standards for professional practice specified in Texas Nursing Practice Act and by HCHD Nursing Service. The practice patterns of competent generalists are characterized by the application of standards, principles, and algorithms to clinical situations. The NCII independently...


  • Houston, United States Heritage Hospice Group Llc Full time

    Job DescriptionJob DescriptionLooking for a Hospice PRN RN!!Primary functions are to administer nursing care for patients in their place of residence, coordinate care with the Interdisciplinary team, patient/family and referring agency, and assume the responsibility for coordination of care.Primarily looking for weekday and weekend coverage, but some normal...


  • Houston, United States Cascades At Jacinto Full time

    Job DescriptionJob DescriptionHello, Cascades at Jacinto in Houston, TX is actively looking to hire a terrific Registered Nurse or LVN to join our nursing team on a PRN basis. We have the following 8-hour shifts available:6A-2P2P-10P10P-6A You will have the opportunity to pick up weekday and/or weekend shifts. Thank you!Job Description:SNF nurses care for...

  • Registered Nurse

    Found in: Jooble US O C2 - 1 day ago


    Houston, TX, United States Travel Nurse Across America Full time

    We're looking for Pediatric Intensive Care Unit RNs for an immediate travel nurse opening in Falls Church, VA. The right RN should have 1-2 years' recent acute care experience. Read below for more requirements. As a PICU RN, you'll provide critical care to pediatric patients as part of a broader medical team. You will collaborate with physicians, specialists...

  • Nurse Clinician II

    Found in: beBee jobs US - 1 week ago


    Houston, Texas, United States tapwage Full time

    Job DescriptionHarris Health System is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness,...


  • Houston, United States Travel Nurse Across America Full time

    We're looking for Neonatal Intensive Care Unit RNs for an immediate travel nurse opening in Richmond, VA. The right RN should have 1-2 years' recent acute care experience. Read below for more requirements. As a NICU RN, you'll provide critical care to sick and premature infants. Alongside the rest of the care team, NICU RNs assist in providing...


  • Houston, United States Travel Nurse Across America Full time

    We're looking for Neonatal Intensive Care Unit RNs for an immediate travel nurse opening in Pittsfield, MA. The right RN should have 1-2 years' recent acute care experience. Read below for more requirements. As a NICU RN, you'll provide critical care to sick and premature infants. Alongside the rest of the care team, NICU RNs assist in providing...


  • Houston, United States Travel Nurse Across America Full time

    We're looking for Pediatric Intensive Care Unit RNs for an immediate travel nurse opening in Charlottesville, VA. The right RN should have 1-2 years' recent acute care experience. Read below for more requirements. As a PICU RN, you'll provide critical care to pediatric patients as part of a broader medical team. You will collaborate with physicians,...


  • Houston, United States Travel Nurse Across America Full time

    We're looking for Pediatric Intensive Care Unit RNs for an immediate travel nurse opening in Charlottesville, VA. The right RN should have 1-2 years' recent acute care experience. Read below for more requirements. As a PICU RN, you'll provide critical care to pediatric patients as part of a broader medical team. You will collaborate with physicians,...


  • Houston, United States Travel Nurse Across America Full time

    We're looking for Pediatric Intensive Care Unit RNs for an immediate travel nurse opening in Charlottesville, VA. The right RN should have 1-2 years' recent acute care experience. Read below for more requirements. As a PICU RN, you'll provide critical care to pediatric patients as part of a broader medical team. You will collaborate with physicians,...

  • PRN Staff Nurse

    2 weeks ago


    Houston, United States Healix, LLC. Full time

    Job DescriptionJob DescriptionHealix Infusion Therapy is seeking a PRN Staff Nurse to coordinate and administer patient care services at one of our Rheumatology Office Infusion Centers located in Houston, TX! As an Infusion Nurse, you will have the opportunity to provide clinical services in an Rheumatology specialty facility. This is an excellent...


  • Houston, United States Harris Health System Full time

      Harris Health System is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management...


  • Houston, United States Senior PsychCare Full time

    **Senior PsychCare** has an immediate opportunity for a** Revenue Cycle Specialist II **to support our Billing Team in Houston. **ABOUT US**: Senior Psych Care provides fully integrative behavioral health services to the long-term care patient, at their facility. Services include individual, family, and group therapies, along with diagnostic evaluation and...