Responsible for the facilitation and management of medical appeals and may assist with clinically oriented claims issues. Investigates and resolves member and practitioner appeals within plan regulatory and accreditation timeframes. Performs ER review activities.We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels.
Primary Duties and Responsibilities
- Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
- Abstracts medical record analyzes clinical information and Approves payment of services in accordance with NCQA Maryland COMAR the District of Columbia contract and MedStar Family Choice Policies/Procedures.
- Conducts an initial medical record review for all clinical appeals including inpatient and outpatient and prepare a summary of the case outlining the issue(s) for the Medical Director’s review. Appeals Nurse prepares a draft response to the appeal for review by the Medical Director in accordance with NCQA Maryland COMAR the District of Columbia contract and MedStar Family Choice Policies/Procedures.
- Conducts an initial review of appeals of emergency room administrative denials against Prudent Layperson Criteria medical necessity appropriateness of coding and health plan policies. Appeals Nurse overturns administrative denials and approves payment when standards are met.
- Conducts an initial review of appeals of emergency room non-administrative denials against Prudent Layperson Criteria medical necessity appropriateness of coding and health plan policies. Appeals Nurse makes a recommendation to uphold or overturn the denial and prepares a draft response for review by the Medical Director in accordance with NCQA Maryland COMAR the District of Columbia contract and MedStar Family Choice Policies/Procedures.
- Coordinates closely with Medical Directors on handling denials adverse determinations or clinically oriented grievances.
- Documents all appeals in an accurate and timely manner per policy related follow-up activities and final outcomes in clinical software system while concurrently maintaining secure comprehensive and clearly defined files.
- Documents ER review activity in the clinical software system.
- Documents in the clinical software system as appropriate. Reviews each appeal received to determine whether the case is a medical appeal or a claim/administrative appeal.
- Forwards recommendation to Deny services to Medical Director. Appeals Nurse will prepare draft of denial reason for MD review in accordance with NCQA Maryland COMAR the District of Columbia contract and MedStar Family Choice Policies/Procedures.
- Participates in inter rater reviews and associated meetings/activities.
- Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.
- Participates in the processing of ER records for appropriateness of service.
- Performs other duties as assigned.
- Performs primary preparation of ER Claims in the clinical software system to administratively deny claims without attached medical records and duplicate submissions.
- Works collaboratively with the Appeals staff Administrative staff and Medical Directors.
Minimal Qualifications
Education
- Bachelor’s degree in Nursing required
Experience
- 5-7 years Diverse clinical experience; experience applying industry standard criteria to clinical information for example interqual. knowledge of common and standard authorization processes. required and
- 1-2 years 2 years of recent utilization review experience. required and
- Prior experience in appeals preferred
Licenses and Certifications
- Active and Unrestricted Nursing License in the State of Maryland required or
- he District of Columbia with a willingness to obtain license in both jurisdictions. required or
- No prior current or pending Medicare or Medicaid sanctions. required and
- No RN license sanctions. required
Knowledge Skills and Abilities
- Ability to read and interpret medical records.
- Ability to abstract analyze and summarize medical/clinical situations.
- Excellent verbal and written communication skills.
- Ability to work independently.
- Ability to prioritize and organize work to meet deadlines.
- Knowledge of medical claims and coding desirable.
- Ability to work effectively in teams.
- Computer/Keyboarding skills and familiarity with Microsoft Office or similar software.
- Maintain current knowledge of MFC policies and procedures and participate in continuing education activities as appropriate.
This position has a hiring range of
USD $89,065.00 – USD $162,801.00 /Yr.
In addition to your salary, MedStar Health offers a comprehensive healthcare package (including medical, dental and vision subject to eligibility requirements) and other benefits. The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by MedStar Health. MedStar Health is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
The hiring range is the range MedStar Health, in good faith, believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on work experience, education and/or skill level, etc. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in MedStar Health’s sole discretion unless and until paid and may be modified at MedStar Health’s sole discretion, consistent with the law.
Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:
- Strong emphasis on teamwork—our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
- Strategic focus on equity, inclusion, & diversity—we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
- Comprehensive total rewards package—including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
- More career opportunities closer to home—as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C. region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.
MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health entities that are federal government contractors are Equal Opportunity and Affirmative Action employers. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health’s policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.
