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Clinical Appeals Registered Nurse
2 months ago
Under the guidance of the Director of Case Management, the Clinical Appeals Nurse is responsible for reviewing and challenging decisions regarding medical services that have been denied, either partially or fully, during the initial claims evaluation process. Denials may arise from inadequate medical documentation, billing discrepancies, utilization assessments, or determinations that the provided treatment was not deemed Medically Necessary.
Key Responsibilities
This job description aims to provide a comprehensive overview of the role; however, it does not encompass all duties that may be assigned. The absence of specific tasks does not exclude them from the position if they are related or logically associated with the role.
- Analyze records to identify potential appeals for denied claims.
- Compose appeal letters grounded in clinical expertise and knowledge, articulated in an objective narrative style, adhering to proper formatting, grammar, and current accepted medical standards.
- Assess denials based on the type, frequency, extent, location, and duration of the patient's medical condition.
- Collect necessary documentation, including prior determination details and complete medical records for thorough review.
- Draft letters in a professional tone, ensuring a detailed review of clinical facts, including medically valid reasons for reconsideration of the denial.
- Submit appeals along with the relevant medical records to the appropriate entities promptly.
- Maintain accurate logs for follow-up purposes, including reports requested by payors.
- Encourage personal professional development by fulfilling requirements for ongoing education and skills competency, while supporting departmental goals that contribute to the organization's success.
- Exhibit adaptability, problem-solving skills, and professionalism consistently.
- Adhere to the Legal Compliance Code of Conduct.
- Safeguard patient confidentiality and manage Protected Health Information (PHI) appropriately.
- Ensure a safe working environment and report any safety concerns as necessary.
- Perform additional related duties as assigned.
Collaboration and Interaction
All roles at Huntsville Memorial Hospital are part of a collaborative team, engaging in the care and service delivery process through effective communication with other team members. The position primarily interacts with hospital personnel, medical staff, patients, and visitors.
Qualifications
Education: Graduate of an accredited nursing program.
Experience: A minimum of two years of experience in managing and facilitating the appeals process for acute care hospital denials is preferred. Familiarity with MCG and InterQual guidelines is advantageous.
Licensure/Certification: Current Registered Nurse license in the state of Texas or eligibility for immediate licensure.
Required Skills: Strong analytical, data management, organizational, and time management abilities are essential.
Physical Demands and Working Conditions
Frequent activities include sitting, standing, walking, and reaching. Occasional tasks may involve lifting, carrying, bending, and squatting. Visual and auditory acuity is required. The work environment is primarily indoors, featuring good ventilation and a comfortable temperature, with occasional outdoor activities that may necessitate driving.
Potential exposure to toxic substances, communicable diseases, and bloodborne pathogens may occur.
Benefits
- Comprehensive Health Care Plan (Medical, Dental & Vision)
- Retirement Savings Plan (401k, IRA)
- Life Insurance Options (Basic, Voluntary & AD&D)
- Paid Time Off
- Short and Long-Term Disability Coverage
- Opportunities for Training and Development
- Access to Wellness Resources
