Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility.
Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services.
The RN will prepare appeal summaries, correspondence and documents.
Request and reviews medical records, notes, and/or detailed bills as appropriate;
Evaluates for medical necessity and appropriate levels of care; formulates conclusions per protocol.
Review governmental contractors response letter in comparison to the medical records
Communicates with facility regarding missing or insufficient medical documentation
Review medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided
Research issues using federal or law, federal regulations, and relevant CMS policies
Identifying root causes for potential denials.
Assures all discussions and appeals are filed timely
Completes data entry in the Denial database for tracking, trends, and analysis
Graduate of an accredited School of Nursing with an Associate or Bachelor's degree (Preferred) in nursing.
Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task
Intensive writing capabilities/efficiencies.
Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff).
Ability to maintain a strong relationship with the staff and work collaboratively to positively affect clinical and financial outcomes.
Assertive and diplomatic communication, proven ability to function on a multidisciplinary team.
Excellent organizational skills including effective time management, priority setting and process improvement.
A minimum of Two to four years Managed Care Appeals, Concurrent Review and/or Case Manager preferred.
Two-three years' experience in the denial and appeal process.
Fundamental claims processing including coordination of benefits and subrogation.
Experience with Managed care, Governmental and/or RAC appeals strongly preferred.
Able to apply InterQual and Milliman Care Guidelines (MCG) medical necessity criteria as applicable.
Understanding of Medicare, Medicaid and third party reimbursement methodologies.
Computer experience in Microsoft Office (Word and Excel).
C. Licenses, Registrations, or Certifications:
Current RN Nursing license
Interqual and/or MCG certification preferred. Case Management (CCM) and Managed Care certification preferred.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.