RN-Clinical Appeals

Under supervision of the Director of Case Management, the Clinical Appeals Nurse, reviews and appeals for reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, and/or determination that the treatment rendered is not Medically Necessary.

ESSENTIAL JOB FUNCTIONS

Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

• Reviews records and determines potential for appeal on denied claims.

• Drafts appeal letters based on clinical judgment and knowledge, written in an objective narrative form, utilizing appropriate formatting, English grammar, current nationally accepted criteria, medical literature if applicable, healthcare statutes and clinical judgment.
• Evaluates denials in terms of type, frequency, extent, site and duration of patient’s illness and/or injury or disease.
• Gathers appropriate documentation which includes previous determination information and complete medical record for review.
• Writes in a professional manner, with an appropriate review of the clinical facts. The letter will include the medically appropriate reasons for the reconsideration of the denial.
• Sends appeals with attached medical records to the appropriate entity in a timely fashion.
• Updates applicable logs for appropriate follow up purposes including payor requested reports.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization. Serves as preceptor, mentor, and resource to less experience staff. 
• Demonstrates adaptability, problem solving and professional behavior at all times.
• Abides by HMH Legal Compliance Code of Conduct.
• Maintains patient confidentiality and appropriate handling of PHI.
• Maintains a safe work environment and reports safety concerns appropriately.
• Performs all other related duties as assigned.

LATITUDE, CONTACTS/INTERACTIONS

All positions of Huntsville Memorial Hospital are part of an interdisciplinary team, and as such, participate in the care and service delivery process through effective interaction with other team members. Primarily interacts with hospital staff, medical staff, patients, and visitors.

Requirements

Education: Graduate of a school of professional nursing.

Experience:  Two years of experience facilitating and managing the appeals process for acute care hospital denials preferred.  Experience with MCG guidelines/ InterQual guidelines preferred.

Licensure/Certification: Current licensure as a Registered Nurse in the state of Texas, or immediately eligible.

Required Skills: Must have strong analytical, data management, organizational and time management skills. 

PHYSICAL DEMANDS AND WORKING CONDITIONS

Frequent: sitting, standing, walking, & reaching.

Occasional: lifting, carrying, bending, & squatting.

Visual and hearing acuity required. Work is mostly inside, with good ventilation and comfortable temperature, as well as outside in the community and could require some driving.

Possible exposure to: toxic/caustic chemicals or detergents, communicable diseases, blood borne pathogens.

Benefits

• Health Care Plan (Medical, Dental & Vision)
• Retirement Plan (401k, IRA)
• Life Insurance (Basic, Voluntary & AD&D)
• Paid Time Off
• Short Term & Long Term Disability
• Training & Development
• Wellness Resources