Appeal Nurse Specialist
3 weeks ago
Our team members are the heart of what makes us better.
At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.
Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.
The Appeal Nurse Specialist will be responsible for the timely review and submission of appeals for denied managed care inpatient and/or outpatient claims to insurance companies for reconsideration of denials and/or level of care change determinations. Gathers and evaluates the information for appeals of Managed Care audits, clinical and technical denials by utilizing various Epic and legacy systems for Hackensack Meridian Health (HMH) hospitals. Responsible for following all regulatory compliance requirements. Serves as a functional expert and liaison to other departments within the hospital system (i.e.: patient access, patient accounting, and Care Management).
Responsibilities:
A day in the life of a Appeal Nurse Specialist at Hackensack Meridian Health includes:
Reviews all retroactive denials in the Epic work queues to assess and evaluate for appropriateness of appeal and identify cases that might require an action other than an appeal letter using department guidelines for such cases (i.e.: Timely Filing Limits, etc.) and mitigate those cases as per Department Guidelines.
Utilizes the evidence-based guidelines in the appeal process. Apply knowledge of MCG Criteria and/or other applicable guidelines for medical necessity, setting and level of care and concurrent denial management.
Educates, trains, and serves as a resource person for the Care Management team, medical staff, residents, and other hospital staff on current utilization review methodologies, requirements and criteria.
Collaborates with the Physician Advisor as needed in the appeal process. Communicate with the Physician Advisor in a timely and professional manner any instances where an alternate level of care billing might be appropriate and accurately document his response as per protocol and communicate this information with appropriate departments such as Access Services, Patient Accounting and Care Management.
Collaborates with third party payers and clinical service lines as needed and provides clinical information as appropriate.
Complete first level Appeals utilizing pertinent clinical information, professional standards and clinical guidelines. Accountable for consistency and accuracy between the department work queue and department worksheet for designated accounts per group assignments on a daily basis.
Monitors retro denials to ensure resolution within required time frames and logging of action e.g. no appeal, appeal level and final decision with revenue impact
Reviews thoroughly all medical records in multiple systems to ensure a complete understanding of the reason for denial in order to proceed in the initiation of a written appeal to the designated Insurance company.
Documents/computer entry on medical records according to Department and Hospital Standards. Coordinates acquisition of appropriate documents, review materials and medical records to facilitate prompt and efficient reviews and appeals.
May be required to Facilitates payer audit requests, i.e. Equiclaim, RAC, etc. for medical necessity denials.
Participate in all Team Huddles and any other department meetings as scheduled.
Adheres to HMH Organizational competencies and standards of behavior.
Other duties and/or projects as assigned.
Qualifications:
Education, Knowledge, Skills and Abilities Required:
Associate degree in nursing from an accredited School of Nursing.
Minimum of three years of acute care nursing experience with knowledge of standard Utilization Management criteria, broad-based clinical knowledge, familiarity with critical pathways, current regulatory requirements, and legislation for third-party payers and payer practice patterns.
Demonstrate qualities including time management, verbal and written communication skills and work organization.
Demonstrates customer-focused and interpersonal skills to interact effectively with physicians, health team members, community agencies, insurers, and clients with diverse opinions, values, and religious and cultural needs.
Excellent written and verbal communication skills.
Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.
Education, Knowledge, Skills and Abilities Preferred:
Bachelor's degree in nursing (BSN).
Experience working in an acute health setting.
Minimum of 1 year of case management or equivalent experience.
Knowledge of Milliman Care Guidelines or Interqual.
Licenses and Certifications Required:
NJ State Professional Registered Nurse License.
Licenses and Certifications Preferred:
Certification in Case Management.
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