UR APPEAL NURSE
KMC Work Location: ARMSTRONG CORPORATE CENTER
Location: Makati, NCR
Date Posted: 2023-07-26
Hiring Organization: KMC Solutions | XTN-CA97248
Career Category: Biotechnology / Pharmaceutical / Medical / Healthcare
Under the direction of the Director of Support Services, this role is responsible for processing clinical appeals for the organization.
• Reviews retrospective clinical denials, both from the Inpatient and Outpatient perspective
• Applies clinical and industry guidelines, and use of in-depth knowledge that supports medical necessity of services rendered
• Conducts patient account history research, including navigating patient encounters and charts, review of uploaded medical records, research of charges, payment histories, & denial reason to determine appropriate course of appeal
• Review cases with screening criteria, such as InterQual, MCG or other appropriate platforms
• Defend and appeal denied claims via written communication in clear and concise rationale in clinical terms/language.
• Navigate multiple IT solutions to ascertain complete clinical and financial information to formulate comprehensive appeals. (A UR Appeal Template & Medical Records are uploaded for quick access/review).
• Continually keep abreast of technology changes, regulatory issues, and medical practice through ongoing training and self-directed research
• Additional functions as deemed appropriate
Provide bi-weekly invoice documenting all letters completed to be submitted to HBS AP DEPT for payment.
• RN with bachelor’s degree in Nursing, Management or related healthcare field.
• Minimum of three (2) years’ experience as Registered Nurse (RN) in an acute clinical setting
• Current and valid RN license within the United States
• Knowledge of InterQual and/or MCG as well as CMS LCD/NCD documentation, no less than 2 years
• Experience in Denials Management, Utilization Management, and/or Appeal research and writing
• Hospital Revenue Cycle Experience preferred
• Proficient in Word and Excel
• Familiar with CPT, ICD-9, ICD-10 and DRG coding preferred
• Basic understanding of Payer Payment Practices & Contracts
• Well-developed verbal and written communication skills coupled with recognizable organization, and prioritization abilities