Appeals AND Grievance Nurse Registered Nurse II PRN - Houston, United States - Christus Health

Description

Summary:

Responsible for the management and communication ofdenials/appeals received from third party payers, managed carecompanies, and/or government entities/auditors related to medicalnecessity and/or level of care. This associate will be a liaisonand point of contact for clinical denials and appeal inquiries. TheClinical Appeals Nurse will review each case identified/referredfor appeal based on Milliman Care Guidelines (MCG), InterQual,and/or other relevant guidelines, determined the viability of theappeal, and manage the appeal process. The Clinical Appeals Nurseis responsible for appealing all inappropriate denials through allpossible levels of the appeal process. The RN Clinical AppealsNurse will actively manage, maintain and communicate denial/appealactivity to appropriate stakeholders, and report suspected oremerging trends related to payer denials. Working with CaseManagement leadership, this individual will orchestrate educationand other performance improvement initiatives to impact clinicalquality, improve efficiency and mitigate lost revenue related tomedical necessity denials. Key Performance and trends related todenials/appeals will be reported to the facility.

• Focuses on the review and analysis ofgovernmental denial rationales and provides appropriate medicalnecessity appeal services
• Review governmentalcontractors response letter in comparison to the medicalrecords
• Communicates with facility regardingmissing or insufficient medicaldocumentation
• Review medical documentation foradherence to Medicare guidelines relating to inpatient services (orother Medicare issues) and draft appropriate appeal letters basedupon professional clinical opinion as to the medical necessity ofthe services provided
• Research issues usingfederal or law, federal regulations, and relevant CMSpolicies
• Communicates with members of thehealthcare team identifying root causes for potentialdenials.
• Communicates with the CMO/VPMAregarding appeals and obtain signature forappeals
• Assures all discussions and appeals arefiled timely
• Completes data entry in the Denialdatabase for tracking, trends, and analysis

Requirements:

• Graduate of an accredited School of Nursingwith a Bachelor's degree in nursing or health relatedfield.
• Excellent verbal and writtencommunication skills, strong listening skills, critical thinkingand analytical skills, problem solving skills, ability to setpriorities and multi-task
• Ability tocommunicate with multiple levels in the organization (e. g.managers, physicians, clinical and supportstaff).
• Ability to maintain a strongrelationship with the medical staff and work collaboratively topositively affect clinical and financialoutcomes
• Assertive and diplomaticcommunication, proven ability to function on a multidisciplinaryteam.
• Excellent organizational skillsincluding effective time management, priority setting and processimprovement.
• Two to four years of UtilizationReview/Case Management experience.
• Two-threeyears' experience in the denial and appealprocess.
• Experience with managed care,governmental and/or RAC appeals stronglypreferred.
• Knowledgeable of InterQual andMilliman Care Guidelines (MCG) medical necessitycriteria
• Understanding of Medicare, Medicaidand third party reimbursement methodologies.
• Computer experience in Microsoft Office (Word andExcel).
• Current RN Nursinglicense
• Interqual and/or MCG certificationpreferred. Case Management certificationpreferred

WorkType:

Per Diem As Needed