Clinical Appeal Nurse
Location:
Houston , Texas
Posted:
December 16, 2017
Reference:
08948-139305
Job Summary - The Clinical Appeals Nurse is responsible for handling appeals requiring clinical input or interpretation.

Duties (included but not limited to):
  • Compose clinical appeal letters to send to payers for denial reconsiderations utilizing documentation, contract language, or voice recordings as applicable
  • Present a concise medical summary within each appeal based on support from the medical record
  • Demonstrate understanding of use of all Medical Necessity software, including but not limited to InterQual©
  • Demonstrate ability to interpret medical payer policy requirements
  • Strong ability to research evidence-based practices
  • Contact appropriate parties (internal and/or external) as needed for additional information to properly formulate the clinical appeal.
  • Determine root cause of each denial and apply company-specific coding for trending and analysis
  • Update the patient account record to identify actions taken on the account
  • Identify problem accounts/processes/trends and escalate as appropriate
  • Complete all required annual training
  • Practice and adhere to the "Code of Conduct" philosophy and "Mission and Value Statement"
  • Other duties as assigned

Qualifications:
Knowledge, Skills & Abilities

Communication - communicates clearly and concisely, verbally and in writing. This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately.

Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations

Interpersonal skills - able to work effectively with other employees, patients and external parties

PC skills - demonstrates proficiency in Microsoft Office applications and others as required

Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems

Technical skills - Professional presentation skills needed to represent facilities in legal issues.

Basic skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately

Clinical skills - ability to read and interpret medical records



Education
  • Associate's Degree preferred


Experience

  • At least one year case management experience required
  • Relevant education may substitute experience requirement


Certificate/License - State RN or LPN License required (Active/Inactive)

#ParallonBCOM



A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom

Know someone who would be interested in this job? Share it with your network.