Clinical Appeals Nurse
3 weeks ago
R1 RCM is seeking a highly skilled Clinical Appeals Nurse to join our team. As a Clinical Appeals Nurse, you will play a critical role in ensuring that our hospital clients receive fair and timely reimbursement for their services.
Key Responsibilities:
- Conduct thorough reviews of patient medical records and payer denial information to assess the entire hospital stay and clinical course of the patient.
- Identify risk factors, comorbidities, and adverse events to determine if payer denial was justified for that hospital stay or service using evidence-based guidelines.
- Review governmental regulations, payer protocols, and/or medical policy to recommend appropriate actions.
- Apply clinical judgment to support medical necessity appeals reviewing against appropriate coverage guidelines.
- Leverage proficient writing skills to prepare written appeals and represent clients at telephonic hearings if needed.
Requirements:
- Active Registered Nurse license
- Experience in a clinical inpatient environment working with a wide range of patient populations
- Ability to use sound judgment in reviewing clinical documentation supporting patient care
- Proficiency in basic computer skills
About R1 RCM:
R1 RCM is a leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. We are dedicated to providing a workplace free from harassment and equal employment opportunities for all.
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Clinical Appeals Nurse
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