Job Description Duties Serve as a clinical resource, provide clinical expertise, and clinical guidance to the team, as well as our client hospitals.
Work with the company’s Attorneys and Account Specialists to overturn claims denied by Commercial insurers, Medicare, Medicaid, and other third-party payers.
Conduct medical chart reviews by reviewing all clinical documentation.
Clinically validate the medical appropriateness, and coding accuracy, of services rendered in both inpatient and outpatient settings.
Reviews admissions for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.
Provides case management and/or consultation for complex cases.
Assists departmental staff with issues related to medical records/documentation, precertification, reimbursement, and claim denials/appeals Create narrative rationale in response to audit and chart review determinations Craft and submit medical necessity and clinical appeals that get denials overturned, as well as guide attorneys to write winning appeals Review clinical policies and guidelines, i.e.
NCD/LCD coverage documents, carrier-specific policies related to investigational or experimental procedures, and readmissions.
Perform chart audits to validate charges as they relate to the services rendered, based on medical documentation Maintain current knowledge of Medicare and Commercial Insurance trends, regulations, and policies.
Perform other related duties as required Requirements Licensed RN –license must be active and in good standing.
Minimum two to five years as a Clinical Appeals Nurse with a main focus on recovering payment for hospitals.
Previous work with an Insurance company will be considered as well.
Experience in defending government audits such as RAC.
Experience/Knowledge in all clinical areas, both inpatient and outpatient, including but not limited to, Cardiology, Pediatrics, Medical-Surgical, Trauma and E.R., Cancer, and Behavioral Health.
Excellent verbal and written communication skills; ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as the ability to understand and interpret complex information from others.
Team Player
– works well as a member of a group