Clinical Appeals Review Nurse

Remote, CA 90802

Industry: Nurse - Compliance/Appeals Job Number: 2501

Purpose: Our Clinical Appeals Review services consists of reviewing and appealing for reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not Medically Necessary.

Essential Job Functions:

Complete the following functions in accordance with Managed Resources policies:
  • The Clinical Appeals Review Nurse will review the case, and determine the potential for a Provider Appeal, on the denied claim.
  • The request for reconsideration will be written in an objective narrative form, utilizing appropriate formatting, English grammar, current nationally accepted criteria, medical literature if applicable, healthcare statutes and clinical judgment.
  • Once completed, the letter will be forwarded to the Clinical Appeals Manager for review and approval and then to the payer source for reconsideration.
  • The Clinical Appeals Review nurse will provide the application of current prudent clinical judgment for the purpose of the case in question.
  • The diagnosis, treatment of an illness, injury, and/or disease of its symptoms, will be in accordance with generally accepted standards of medical practice.
  • The clinical review of the denied stay will be evaluated in terms of type, frequency, extent, site and duration of patient’ s illness and/or injury or disease.
  • The clinical review of the case will not be based on convenience factors for the patient, facility, physician, and/or other health care professionals.
  • The Clinical Appeal Review Nurse will receive appropriate documentation which includes previous determination information and complete medical record for review.
  • The review will be written in a narrative, professional manner, with an appropriate review of the clinical facts. The letter will include the medically appropriate reasons for the reconsideration of the denial.
  • Once the review is completed, the Clinical Appeal Review Nurse will forward the reconsideration letter to corporate office, through secure website, for review by the Clinical Appeals Manager. Once approved, the letter is mailed with attached medical records to the appropriate entity.
  • The Clinical Appeals Review Nurse will then update the applicable logs for appropriate follow up  purposes including payor requested reports.

Ideal candidate will possess the following:
  • RN (preferred) or LVN with comparable experience and background. Certification in Case Management, Legal Nurse Consulting, or Coding a plus. 
  • Five years of acute hospital experience mandatory.
  • Possess knowledge and experience with national clinical criteria applied in case management including InterQual and Milliman standards.
  • Working knowledge of billing codes, Revenue Codes, CPT’ s, etc. Experience with case management software such as Midas preferred.
  • Experience and knowledge of managed care contracts, account receivables and revenue cycle functions.
  • Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry based standards.
  • Experience and success in appealing managed care denials and underpayment decisions.
  • Ability to examine financial and clinical data trends and provide recommended action steps to resolve. 

Managed Resources is an Equal Opportunity Employer (EOE) M/F/D/V/SO

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