Appeals Writer PHRN

Experience these Xtraordinary benefits when you join Med-Metrix

• 8-Hour Shifts, Fixed Weekends Off
• Day 1 HMO with 2 of your dependents covered for FREE
• Medical Cash Allowance
• Rice Allowance
• Clothing Allowance
• Free Lunch Daily
• Paid Time Off
• Training and Staff Development
• Employee Engagement Activities
• Opportunities for Internal Mobility

The Appeals Writer supports the Company by reviewing insurance claims denied for payment on behalf of our client hospitals. Working closely with nurses and other team members, the Appeal Writer creates appeal letters in support of claim payment.

Duties and Responsibilities

• Review and analyze appeals and grievances to determine appropriate resolutions
• Ensure compliance with CMS (Centers for Medicare & Medicaid Services) regulations and guidelines, and client specific rules
• Conduct thorough investigations, including gathering and reviewing medical records, provider documentation, and member information
• Prepare detailed case summaries and decision letters
• Communicate effectively with members, providers, and regulatory agencies to resolve issues
• Maintain accurate and up-to-date records of all appeals and grievances
• Identify trends and provide recommendations for process improvements
• Collaborate with internal departments to ensure timely and accurate resolution of cases
• Ability to work in a fast paced and production environment
• Review denied insurance claims
• Review patients' medical files
• Develop strategies to reverse claim denials
• Create written appeals
• Manage and organize appeal workflow based on internal, client-based, and insurance-driven deadlines
• Use, protect and disclose patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

Qualifications

• Must be a Registered Nurse. US RN, not required
• Must have at least 1 year of strong clinical experience in direct patient care within acute setting such as ICU, ER, Med-Surg, or general acute care units
• Must have effective English communication skills in both written and verbal
• Must possess a high level of reading comprehension and ability to analyze medical information and terminology

Working Conditions

• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.