Claims Denial Nurse

We are recruiting for a Clinical Appeals Nurse to join our Clinical Denials Management Department for the Hospital Division. This is a work from home position that can live anywhere.

We currently have two (2) positions available.

Responsible for denial assessment, analysis of clinical documentation, and formulation of appeal letter when medical necessity and non-clinical denials are received from third party payers (government and non-government). Writes claim appeal letters according to evidence in the medical record and defined appeal process. Ensure timely submission of appeal letters, per internal expectations and payer guidelines.

Essential Functions:

• Excellent writing skills.
• Excellent computer skills with working knowledge of Microsoft Office, word-processing and spreadsheet software.
• Knowledge of accreditation standards and compliance requirements.
• Knowledge of government and non-government payer practices, regulations, standards and reimbursement processes.
• Knowledge of established national medical necessity guidelines (InterQual(r) level of care LTAC criteria, Milliman Care Guidelines(r) for LTAC).
• Compose appeal letters for the Hospital Division, including Inpatient Rehabilitation Facilities (IRFs).
• Ability to review medical, financial and admission criteria documentation to prepare well-written appeal letters.
• Ability to communicate whether denial is substantiated or viable after review of medical, financial, and admission documentation.
• Regularly review periodicals, web sites and other media for changes in current guidelines.
• Provide educational material relative to types of claims and errors identified during review of medical and financial documentation.
• Recommend projects that promote documentation improvement (i.e. form, ProTouch, other documentation standardization/ compliance projects) reducing risk of denied claims.

Knowledge/Skills/Abilities:

• Working knowledge of healthcare law.
• Strong written and verbal communication skills.
• Ability to work with individuals at all levels of the organization.
• Knowledge of long-term acute care industry.
• Knowledge of state and federal regulations.
• Proficient computer skills.
• Ability to analyze, research, and interpret.

• Bachelor's degree in clinical field required
• Registered Nurse preferred
• 5+ years of experience in clinical setting required
• 1+ years experience in hospital case management preferred