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Appeals Nurse Coordinator

1 month ago

Franklin, Tennessee, United States XSOLIS Full time
About Us

Xsolis is a cutting-edge technology company that revolutionizes the healthcare industry with its AI-driven platform, Dragonfly. This innovative solution provides real-time predictive analytics, enabling more efficient outcomes and accurate medical necessity decisions. Headquartered in Franklin, Tennessee, Xsolis fosters collaboration between healthcare providers and payers through transparency and objective data.

Our Values:
  • Team First
  • Client Passionate
  • Always Curious
  • Deliver Excellence
Xsolis has been recognized as a fastest-growing private company by the Inc. 5000 and Deloitte Technology Fast 500 lists in 2022 and 2023. We were also named 2022 Best in Business by the Nashville Business Journal. Our executives have been featured in leading publications, including Becker's Hospital Review and CIO Review.

Position Summary

The Appeals Nurse Coordinator will provide concurrent review and appeal support services for Xsolis's growing client base. This role requires experience with utilization management, DRG clinical validation, and knowledge of state and federal regulations. The ideal candidate will have expertise in the denials and appeals process, physician documentation, and electronic health records.

Key Responsibilities

The Appeals Nurse Coordinator will be responsible for:
  • Providing clinical reviews in accordance with Managed Care and CMS Regulatory Requirements
  • Assisting with assigning appropriate levels of care on a case-by-case basis
  • Determining if ICD-10 codes/DRG are appropriately documented and meet clinical documentation integrity guidelines
  • Assisting with the denial management process and construction of appeal correspondence
  • Determining if professionally recognized standards of quality care are met
  • Providing feedback to internal and external partners regarding level of care, length of stay, and clinical documentation
  • Applying clinical and industry guidelines to support medically necessary services and clinical documentation integrity
  • Identifying opportunities to request additional medical record documentation
  • Reviewing cases with screening criteria, such as InterQual and MCG
  • Continually keeping abreast of technology changes, regulatory issues, and medical practice through ongoing training and self-directed research
  • Providing clients with detailed summaries of cases to track trends and pertinent information
  • Researching and reviewing contracts and speaking with payers on behalf of clients
  • Ensuring legal compliance by following guidelines, contracts, regulations, and the company's business plan
Requirements

The ideal candidate will have:
  • Active RN or LPN license
  • 3-5 years of clinical practice, with at least 2 years in auditing, appeals, medical review, and CDI
  • Case management or utilization review experience and CM, coding, and/or CDI certification a plus
  • Experience working with multiple instances of Electronic Medical Records (i.e. Meditech, Cerner, EPIC)
  • Knowledge of the query process and utilization of CDI guidelines (Pinson & Tang, ACDIS, etc.)
  • Experience using case management guidelines (InterQual, Milliman, CMS 2MN Rule)
  • Excellent communication skills
  • CPT, ICD-10, and DRG coding
  • MS Office Suite - Specifically Word and Excel
  • Organization and prioritization
  • Medical record technology
  • Adobe DC/PDF
Working Environment and Travel Requirements

The Appeals Nurse Coordinator will work in a normal office administrative environment with minimal exposure to physical risks. The position requires little to moderate physical activity, with mostly sedentary work involving sitting most of the time. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.