Clinical Appeals/CCS Nurse
11 Golden Shore Suite 360 Remote, CA 90802
The Clinical Appeals/CCS Nurse reviews and analyzes denied/downgraded MS-DRG and APR-DRG accounts received from payers (e.g., Medicare, Commercial and Third Party). Utilizing clinical and coding expertise, the Nurse will render a determination on whether or not the denied/downgraded account is appealable. The Clinical Appeals/CCS Nurse will provide an appeal letter based on current coding guidelines and clinical criteria as well as track and trend denial root causes for the specific coding denial
Essential Job Functions:
Complete the following functions in accordance with Managed Resources policies:
? Serves as liaison with third-party payers/agencies regarding appeals to ensure optimal reimbursement and any other billing/payment issues or questions are resolved.
? Develops recommendations to maintain efficient and effective processes.
? Identifies coding and clinical documentation issues and provide proactive recommendations to clients.
? Identifies problem accounts and escalates as appropriate.
? Updates patient account record to identify actions taken on the account.
? Ability to write clearly and concisely, handle necessary technical vocabulary and organize difficult or complex information in an understandable and efficient manner.
? Responsible for favorable resolution of third party payment denials, adverse determinations, medical necessity denials, payment discrepancies and contract misinterpretations.
? Reviews whether DRG' s are assigned correctly, and if all diagnoses and procedure codes are identified and documented.
? Performs other duties as assigned.
Ideal candidate will possess the following:
? Graduate of an accredited College or University, BSN preferred? Active Registered Nurse licensure required
? Must have CCS Certification, AHIMA
? Minimum of 3 years of clinical experience preferably in Hospital inpatient and outpatient department
? Preferred 2 years of case management experience.
? Working knowledge of InterQual and Milliman Care Guidelines as well as payer specific medical guidelines and how to apply them in an appeal.
? Experience with Inpatient claims is a plus.
? Experience in a variety of EMR (Epic, Cerner, etc.) and Coding Reimbursement Systems, i.e. 3M, Nuance.
? Excellent oral and written communication skills, including the ability to interact with high-level of management.
? Excellent organizational skills, with a strong focus on detail.
? Ability to work independently and multi task in a fast paced, changing, health care environment.? Ability to organize, plan, prioritize, and complete assignments within the required time frame.
? Responsible for preparing clear and concise audit reports.
Managed Resources is an Equal Opportunity Employer (EOE) M/F/D/V/SO