The Clinical Appeals RN will manage patient cases on specialty drug programs after a claim or prior authorization has been denied by either a commercial or a government payer and when a letter of medical necessity (LMN) is warranted. In this position, the Clinical Appeals RNs' responsibilities include managing client medical or pharmacy denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Clinical Appeals RN will write and/or consult factual arguments. The Clinical Appeals RN will also review and provide clinical references to support the Letter of Medical Necessity for the submission of the appeal case to the insurance plan.
The RN works with appeals and denials by:
- reviewing, researching and preparing 2nd level appeals functions utilizing clinical expertise;
- reviewing clinical notes and other supporting documents from the patient medical record;
- verifying claim denials and accurately entering data into appropriate databases.
Assists in bringing resolution to insurance claim denials/rejections by:
- reviewing Explanation of Benefits (EOBs) or payer denial letter to determine the reason for rejection or denial, as well as identifying potential solutions;
- gathering, documenting, and tracking payer intelligence related to appeal policies and requirements.
The Clinical Appeals RN may
- work with appeals and denials by communicating on a clinician-to-clinician level to evaluate patient needs;
- perform claim investigative work according to guidelines and performance standards;
- draft appeal letters for HCP review (using client provided/approved appeal letter templates) submitting to the appropriate payer, and following-up as needed until a decision is reached;
- research and coordinate external reviews;
- participate via conference call when necessary to provide relevant support;
- assist and provide guidance to non-clinical Reimbursement associates with appeals;
- be required to attend hearings, handle audit-related correspondence, and other administrative duties as required;
- communicate updates (i.e., tracking and trending) to management relative to negative claim payment/coverage from insurers for reporting to the manufacturer.
PRIMARY DUTIES AND RESPONSIBILITIES:
EXPERIENCE AND EDUCATIONAL REQUIREMENTS:
- Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
- May utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.
- Uses client approved clinical articles or if unavailable, may search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
- Prepare feedback to clients and participate in client meetings.
- Receiving, documenting, investigating, and coordinating appeals.
- Understanding and interpreting payer guidelines and policies from a clinical perspective
- May draft, submit and track action on appeals letters, reconsideration and re-determination requests and other communication with medical payers on behalf of providers and patients.
- May interpret clinical information, performing searches for relevant articles and assisting the customer through education and clear communication.
- Tracking the status of outstanding appeals and trending appeals successes to help develop internal appeal strategies for specific payers.
- Working off of a task list ensuring timelines and customer commitments are met.
- May work to minimize obstacles to coverage by using judgment to successfully plan next steps.
- May make case assessments and making informed, methodical decisions throughout a very complex process.
- Supporting the management team on program initiatives
- May perform tele-health duties as dictated by program needs
- Additional duties as assigned.
- Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting or medical insurance setting. In addition, having at least two to three years' experience in case management, discharge planning, and/or utilization review is preferred.
- Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by insurance plans.
- Experience at an insurance company in a clinical review capacity, or medical office experience with clinical review/PA experience, or direct appeals experience is preferred.
- Full understanding of the insurance claim submission / approval / denial / appeal process; previous direct experience in submitting appeals and advocating for appropriate clinical treatment of patients is highly desired.
- Registered nurse possessing a current license issued by a state or jurisdiction within the United States, and unrestricted in any state.
- BSN preferred.
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