Clinical Appeals Nurse

1 week ago


Huntsville, Texas, United States Huntsville Memorial Hospital Full time
Job Title: Clinical Appeals Nurse

At Huntsville Memorial Hospital, we are seeking a highly skilled Clinical Appeals Nurse to join our team. As a Clinical Appeals Nurse, you will play a critical role in reviewing and appealing denied medical services, ensuring that our patients receive the care they need.

Key Responsibilities:
  • Review medical records and determine potential for appeal on denied claims.
  • Draft appeal letters based on clinical judgment and knowledge, utilizing appropriate formatting and language.
  • Evaluate denials in terms of type, frequency, extent, site, and duration of patient's illness or injury.
  • Gather appropriate documentation, including previous determination information and complete medical records.
  • Write professional appeal letters, including medically appropriate reasons for reconsideration of denial.
  • Send appeals with attached medical records to the appropriate entity in a timely fashion.
  • Update applicable logs for follow-up purposes, including payor requested reports.
  • Promote individual professional growth and development through mandatory/continuing education, skills competency, and department-based goals.
  • Demonstrate adaptability, problem-solving, and professional behavior at all times.
  • Abide by HMH Legal Compliance Code of Conduct and maintain patient confidentiality.
Requirements:
  • Graduate of a school of professional nursing.
  • Two years of experience facilitating and managing the appeals process for acute care hospital denials preferred.
  • Experience with MCG guidelines/InterQual guidelines preferred.
  • Current licensure as a Registered Nurse in the state of Texas, or immediately eligible.
  • Strong analytical, data management, organizational, and time management skills.
Benefits:
  • Health Care Plan (Medical, Dental & Vision)
  • Retirement Plan (401k, IRA)
  • Life Insurance (Basic, Voluntary & AD&D)
  • Paid Time Off
  • Short Term & Long Term Disability
  • Training & Development
  • Wellness Resources


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