Clinical Appeals Nurse - Remote - $10K Sign On Bonus
The Revenue Cycle Clinician for the Appellate Solution is responsible for:
Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
Preparing and documenting appeal based on industry accepted criteria.
Essential Duties And Responsibilities
Performs retrospective (post–discharge/post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter‑rater reliability studies and other QA audits. Constructs and documents a succinct and fact‑based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process.
Adheres to the department standards for productivity and quality goals, ensuring accounts assigned are worked in a timely manner based on the payor guidelines.
Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office.
Demonstrates basic patient accounting knowledge: UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc.
Additional responsibilities:
Serves as a resource to non‑clinical personnel.
Provides CRC leadership with sound solutions related to process improvement.
Assists in development of policy and procedures as business needs dictate.
Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.
Knowledge, Skills, Abilities
Demonstrates proficiency in the application of medical necessity criteria, currently InterQual®
Possesses excellent written, verbal and professional letter writing skills
Critical thinker, able to make decisions regarding medical necessity independently
Ability to interact intelligently and professionally with other clinical and non‑clinical partners
Demonstrates knowledge of managed care contracts including reimbursement matrices and terms
Ability to multi‑task
Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
Ability to conduct research regarding off‑label use of medications.
Education / Experience
Must possess a valid nursing license (Registered)
Minimum of 3 years recent acute care experience in a facility environment
Medical‑surgical/critical care experience preferred
Minimum of 2 years UR/Case Management experience preferred
Managed care payor experience a plus either in Utilization Review, Case Management or Appeals
Previous classroom-led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred
CERTIFICATES, LICENSES, REGISTRATIONS
Current, valid RN licensure (Must)
Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR, CPUM, or CPHM) preferred
PHYSICAL DEMANDS
Ability to lift 15-20 lbs
Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites
Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews
WORK ENVIRONMENT
Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
Other
May require travel – approximately 10%
Interaction with facility Case Management, Physician Advisor is a requirement.
Compensation
Pay: $30.85 - $46.28 per hour. Compensation depends on location, qualifications, and experience.
Position may be eligible for a signing bonus for qualified new hires, subject to employment status.
Conifer observed holidays receive time and a half.
Benefits
Medical, dental, vision, disability, and life insurance
Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
401(k) with up to 6% employer match
10 paid holidays per year
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.