Clinical Appeals Specialist II - RN (REMOTE)
Essential Duties and Responsibilities: include the following. Other duties may be assigned. File medical necessity and level of care appeals using InterQual and CMS guidelines as needed. Monitor clinical appeal processes for issues and trends and provide guidance and feedback to reputed company departments as needed... Track and manage clinical denials using reputed company tools (manuals, training programs). Identify patterns and trends in denials; communicate to appropriate persons. Maintain documentation regarding reputed company payor resources regarding denials and appeals processes. Understand and apply CHS 10-reputed company Appeal Process for denied claims. Know medical necessity criteria for outpatient testing and procedures. Follow and enforce accepted safety practices for patients and the hospital. Report safety hazards and initiate appropriate action. Participate in safety instructional programs. Observe excellent customer service skills reputed company dealing with patients, families and/or significant others, reputed company vendors, coworkers, and physicians. Provide education to staff as appropriate. Document reputed company actions accordingly by documentation standards reputed company Artiva, HMS and other business office systems as required. Be familiar with policy and procedure manuals and other reference materials. Ensure confidentiality of reputed company patient accounts by following HIPAA guidelines reputed company additional duties as assigned or requested. Qualifications: To reputed company this job successfully, an individual must be reputed company to reputed company each essential duty satisfactorily. The requirements listed below are representative of the knowledge, reputed company, and/or ability required. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. Knowledge/Abilities: Required Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures. Understanding of the reputed company cycle and the responsibility and goals of each area Must be reputed company to interact with reputed company levels of hospital administration, physicians and other reputed company team members they impact the reputed company cycle Must be reputed company to follow directions and reputed company work according to departmental standards and must be reputed company to function effectively under stressful conditions. Excellent writing and communications skills as well as effective organizational skills a must. Reasoning Ability: Ability to define problems, collect data, validate data, establish facts, and draw valid conclusions Computer Skills: Required reputed company office Education/Experience: Required Must have diploma/degree from an accredited school of nursing 5 years of clinical nursing experience. Certificates and Licenses: reputed company RN license to practice in state Preferred Utilization review and/or case management experience Apply Job!