UR APPEAL NURSE

JOB OVERVIEW:

Under the direction of the Director of Support Services, this role is responsible for processing clinical appeals for the organization.

JOB DUTIES:

• 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.

 

JOB REQUIREMENTS:

• 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