Clinical Appeals Nurse Writer

Clinical Appeals Nurse Writer (USRN/PHRN) The Clinical Appeals Nurse is responsible for creating a convincing and effective appeal based on clinical documentation, payer-specific standards, and compliance with federal and state policies. The Clinical Appeals Nurse handles clinical denial appeals and follow-up, provides denial information to departments to ensure that systems, processes, and effectiveness measures are created and implemented to resolve root cause issues and reduce/eliminate denials. The Clinical Appeals Nurse ensures that appeals are filed on time. Essential Duties and Responsibilities Performs medical record reviews concurrently and/or retrospectively to determine why cases are denied and whether an appeal is required. Review clinical denials promptly and appropriately, utilizing clinical criteria sets such as InterQual® criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medically necessary services denied for lack of authorization. Write an effective and efficient appeal based on clinical documentation, payer-specific policies, and client-specific instructions. Think critically and use clinical judgment in providing effective and well-supported appeals. Maintain thorough and current knowledge in clinical expertise and stay relevant in the fast-changing trends in healthcare, reimbursement methodologies, and utilization. Demonstrate basic patient accounting knowledge, e.g., UB04 claim form and Explanation of Benefits (EOB) components, adjustments, credits, debits, balance due, patient liability, etc. Read and understand medical abstract information from handwritten to typed medical records. Demonstrate proficiency in the use of electronic tools and competency in Microsoft Office. Observe specific payer guidelines for appeal submission and ensure compliance with law and regulations. Other tasks/functions that may be assigned by the company as per business requirements; these may change from time to time to reflect changing requirements of the position and business. Minimum Required Qualifications (Skills, Knowledge, and Abilities) Education Graduate of BS in Nursing Strong writing and grammatical skills Above-average written and verbal communication skills Certification/Licensure Must be a Registered Nurse Knowledge and Skills Demonstrates proficiency in the application of medical necessity criteria. Ability to conduct intensive research regarding State/Federal guidelines and other regulatory processes. Must have experience in writing appeals. Excellent communication skills in verbal and professional letter writing. Able to think critically. Ability to multitask. Ability to work with minimal supervision and work under pressure within the given timeframe. Benefits Temporary Work From Home Setup 30k Sign On Bonus Seniority level Entry level Employment type Full-time Job function Health Care Provider Industries Hospitals and Health Care We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI. #J-18808-Ljbffr