Clinical Appeals Nurse

Imagine a career at one of the nation's most advanced health networks.

Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work.

LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary
Reviews payor denials and audits for potential lost revenue. Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. Functions as a hospital liaison with external third-party payors to appeal denied claims. Works closely with Physician advisor team to facilitate appeals to payors. Monitors and reports payor trends to management team.

Job Duties

• Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor and the documentation found in the hospital/physician information system.
• Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor to meet their guidelines.
• Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials.
• Contacts insurance companies and conducts appeals via telephone or email.
• Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights.
• Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors.
• Ensures that all appeals are sent to the correct payor within the appeal guidelines.
• Ensures compliance with regulatory and accrediting requirements.
• Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor.
• Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

Minimum Qualifications

• Bachelor’s Degree Nursing or
• Specialized Diploma
• 10 years of clinical or case management/utilization review experience
• Ability to read medical charts and identify deficiencies in documentation content.
• Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
• Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
• Knowledge of coding for payment of claims.
• Insurance knowledge of payors and their unique rules.
• Epic workflow experience with notes in account history and WQ workflows.
• Intermediate Excel and MS Word experience.
• Must complete RCE Training and pass test with 80% or better.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania

Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.

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Lehigh Valley Health Network does not accept unsolicited agency resumes. Agencies should not forward resumes to our job aliases, our employees or any other organization location. Lehigh Valley Health Network is not responsible for any agency fees related to unsolicited resumes.

Work Shift:

Day Shift

Address:

1200 S Cedar Crest Blvd

Primary Location:

REMOTE IN PENNSYLVANIA

Position Type:

Remote

Union:

Not Applicable

Work Schedule:

Monday-Friday 8:00 am-4:30 pm

Department:

1004-13060 CSS-Clinical Appeals - Denial Mgmt