Full-Time Clinical Appeals Nurse

The Clinical Appeals Nurse is responsible for managing medical denials by conducting a comprehensive review of clinical documentation to determine if medical necessity criteria are met.

Where an appeal is warranted, the Clinical Appeals Nurse consults with healthcare providers, patients, and the medical record to compose sound, compelling, factual arguments for submission. They manage the appeals process within prescribed timeframes to meet departmental goals.

Attendance at Administrative Law Judge Hearings may be required.

Essential Duties and Responsibilities:

• Successfully manage the appeals process from beginning to end within the designated timeframe.
• Ensure appropriate communication with patient, insurance company, and internal business partners.
• Ensure compliance with HIPAA regulations, including confidentiality.
• Perform all other duties as assigned.

Expectations of the Job:

• Determine why cases are denied and if an appeal is warranted using knowledge of payer requirements and medical chart data.
• Utilize pre-existing criteria, clinical evidence, and resources to develop sound appeal arguments.
• Generate appropriate appeal resolution communication to the member and provider.
• Request additional information from providers, as appropriate, for timely appeals.
• Gather and prepare case information for Administrative Law hearings.
• Summarize and present appeal outcomes to clients and participate in client meetings.
• Review documentation related to level of care decisions with clients.

Minimum Knowledge, Skills, and Abilities:

• Bachelor’s Degree in Nursing
• Current MO RN license in good standing
• 4 years’ experience as a clinical nurse in an acute care setting
• Knowledge of third-party payer regulations
• Analytical, creative, and interpersonal skills
• Excellent communication (written, verbal, and presentation) skills
• Strong clinical and regulatory knowledge, payer requirements knowledge
• Strong organizational skills
• Demonstrated sense of urgency

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