Job Summary - The Clinical Appeals Nurse is responsible for providing clinical input or interpretation for denials that have remained unresolved or have been escalated under the Shared Service Center (SSC) operations pre-established protocols. This position will be critical in supporting the payer specialization strategy focused on denial cash conversion and ultimately avoidance. Tracking large case volumes efficiently and effectively, with technology, while providing the highest levels of customer service and attention to details is required. Success in this position will be indicated by a high volume of throughput, meaningful engagement with the Physician Adviser, Attorneys and other members of the Payer Specialization Team, and successful denial overturns.
Transition Duties (included but not limited to):
- Responsible for building, supporting implementation and maintaining high quality processes in order to maximize net revenue.
- Leverage new and existing technology capabilities accordingly and integrate into operational processes.
- Manage transition and business continuity of processes between the Payer Specialization Team, the SSCs and other stakeholders; engage other corporate support departments such as Education, Project Management, HR, SMEs etc. accordingly.
- Champion change management programs, with strong focus on effective and timely communication to the Payer Specialization Team, SSCs, corporate departments, payers and other stakeholders.
Operational Duties (included but not limited to):
- Compose, edit, review, or otherwise support concise next-level appeal evaluations for disputed claims through review and assessment of clinical appeal letters, denial reconsideration documentation, payer denial documentation, medical records, other relevant documents; recommend next steps for resolution.
- Assist in the authoring of complex contractual appeals and demand letters to insurance companies.
- 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 and evaluate clinical appeals.
- Determine root cause of denials and apply company-specific coding for trends and analysis.
- Utilize computer programs and software to ensure assigned cases are tracked and monitored in an efficient and effective manner.
- Communicate with peer-level provider representatives (call, e-mail and/or meetings) to resolve complex claim and appeal issues.
- Assist the Payer Specialization Team in denial avoidance and cash conversion strategies through the development of new and innovative methods and processes.
- Review and apply contract language as necessary to resolve denied claims.
- Utilize payer administrative manuals to dispute denied claims.
- Maintain and apply understanding of federal, state and local rules and regulations impacting denials and appeals.
- Maintain and apply understanding of HCA / Parallon policies and procedures and work protocols impacting denials and appeals.
- Bachelor Degree preferred
- At least one year case management or similar appeal experience required
- Relevant education may substitute experience requirement
- State RN or LPN License required (Active/Inactive)
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