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RN Clinical Appeals (Part Time)- AHN, PA
J273408
Company :
Allegheny Health NetworkJob Description :
GENERAL OVERVIEW: Responsible for all aspects of clinical appeal activities to include but not limited to, clinical record review, composing comprehensive appeal letters and compiling minimum necessary documentation to support services performed. Addresses and resolves potential and actual denials for assigned accounts as well as collaborates with AHN departments/Teams in denial prevention activities. ESSENTIAL RESPONSIBILITIES- Reviews clinical denials, audits and accounts as assigned. Composes and submits a comprehensive appeal letter based on clinical evidence within the medical record and evidence based literature. (40%)
- Submits appropriate clinical documentation while ensuring compliance with HIPAA regulations and confidentiality to support for the appeal. Follows account to resolution to include appropriate financial adjustment. (40%)
- Partners with other AHN departments to find resolution for payor and/or customer issues. (5%)
- Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies. (5%)
- Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies for improvement. (5%)
- Participate in denial reduction/prevention activities through denial root cause identification and trending as well as active participation in payor related calls and/or internal work groups. (5%)
- Performs other duties as assigned or required.
- High School / GED
- 3 years in a nursing role
- Proficiency in Microsoft Office (Word, Excel, Outlook, etc.)
- Strong and effective verbal and written communication skills.
- Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
- Bachelor's Degree in Nursing
- 1 year in Utilization Management or Utilization Review
- 1 year in Case Management
- 1 year with continuous documentation improvement
- CPR certification
- Appeals Experience
- Knowledge of CMS regulations and/or third party payer requirements for reimbursable care
