Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility.
o Current RN Nursing license o Interqual and/or MCG certification preferred. Case Management (CCM) or Managed Care certification preferred.
Graduate of an accredited School of Nursing with an Associate or Bachelor's degree (Preferred) in nursing
o Two to four years of Case Management experience. o Two-three years' experience in the denial and appeal process. o Experience with managed care, governmental and/or RAC appeals strongly preferred. o Able to apply InterQual and Milliman Care Guidelines (MCG) medical necessity criteria to a case as applicable. o Understanding of Medicare, Medicaid and third party reimbursement methodologies.
Ability to perform the essential functions of this position, with or without reasonable accommodation and without posing a direct threat to the health and safety of self or others. Ability to comply with all Good Shepherd policies and procedures that are job-related and consistent with business necessity. Ability to effectively communicate with patients and provide competent care as appropriate to the ages of patients served by this position.
o Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task o Intensive writing capabilities/efficiencies. o Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff). o Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomes. o Assertive and diplomatic communication, proven ability to function on a multidisciplinary team. o Excellent organizational skills including effective time management, priority setting and process improvement.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.