Full-Time Clinical Appeals Nurse

THE POSITION: 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 in order to meet the operational goals of the department. Attendance at Administrative Law Judge Hearings may be required.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Successfully managing the appeals process from beginning to end within the designated timeframe
• Ensuring appropriate communication through the process with patient, insurance company and internal business partners
• Ensuring compliance with HIPAA regulations, to include confidentiality, as required
• 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 with medical chart data
• Utilize pre-existing criteria, clinical evidence and other resources as needed to develop sound and well-supported appeal arguments
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies
• Request additional information from providers, as appropriate, to facilitate timely appeals
• Gather and prepare case information for participation in Administrative Law hearings
• Summarize and present appeal outcomes to clients and participate in client meetings as needed
• Reviewing documentation related and 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 related to utilization and quality review
• Analytical, creative, and interpersonal skills
• Excellent communication (written, verbal, and presentation) skills
• Strong clinical and regulatory knowledge and skills as well as knowledge of payer requirements
• Strong organizational skills
• Demonstrated sense of urgency to drive to successful outcomes within the minimum required time frames

PREFERRED QUALIFICATIONS:

• 2 years’ experience in case management, discharge planning, and/or utilization review
• Experience with infusion and home health services as well as managed care
• Experience working with patient consumers with rare chronic disorders
• Exhibits an upbeat attitude, a genuine interest in others and a sense of humor. Energizes others and heightens morale through her/his attitude
• Commitment to teamwork
• Creates a climate that motivates and encourages others to participate
• Transforms creative ideas into original solutions that positively impact the company’s performance
• Proves to be a professional of unquestionable integrity, credibility and character who demonstrates high moral and ethical behavior

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