Clinical Denials RN (Remote), IL

10299 Enterprise Revenue Cycle – Revenue Recovery Appeals: MW 

Full time 

Yes 

40 

Fully remote full time position

Pay Range

$38.20 – $57.30 

Major Responsibilities:

• Utilize clinical nursing expertise to assess denied claims to ensure timely evaluation and response and makes a determination whether or not the case is eligible for appeal by applying clinical and regulatory knowledge and using established clinical level of care criteria, documentation of medical necessity and appropriateness of status order.
• Utilize industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, and best practice standards, as well as a broad knowledge base and sound clinical judgment in reviewing medical records and writing appeals.
• Research and analyze denied claims using payor and government rule and regulations and makes a determination whether or not the case is eligible for clinical appeal by using third party requirements
• Conducts concurrent and retrospective clinical review based upon pre-established criteria approved by the Medical Staff for medical necessity appropriateness.
• Continues the appeal process until the case is overturned, appeal options are exhausted or decision is made to discontinue the process and is responsible for ongoing documentation of denial status in denial software.
• Prepares denials for clinical appeal processing in the case of authorization, coding, level of care and/or length of stay denials. Write appeal letters based on medical necessity
• Prioritizes appeals according to filing limitations established by the individual payor contracts and/or with governmental bodies. Secure needed medical documentation required or request by insurance carries to support the appeal process.
• Works to minimize third party payer denials. Identifies trends in claim denials and partners with various departments, including business office, pre-service, case management, utilizations management, contracting, audit, and physician advisors as deemed necessary, in an effort to provide education and/or corrective action to errors related to admission, charging, coding, documentation, patient status or billing.
• Provide support and clinical expertise to assist in resolving issues with third party payers during operational review meetings. Assist in documenting issues and trends that prevent payment of claims for service.

Licensure:

• Nurse, Registered (RN)

Education/Experience Required:

• Bachelor’s degree in Nursing

Knowledge, Skills & Abilities Required:

• Experience with current CPT and HCPCS coding nomenclature and rules, ICD10 coding conventions and clinical documentation standards.
• Previous clinical/technical documentation and chart review experience along with understanding of medical terminology.
• Knowledge of appeals criteria and understanding of federal, state and local regulations.
• Experience with level of care criteria (MCG and/or InterQual) and clinical documentation standards.
• Excellent critical thinking and analytical skills, with a high attention to detail. Ability to meet deadlines while independently working in a fast-paced environment.
• Ability to take initiative and work collaboratively with others.
• Strong computer skills, including high proficiency with Microsoft Office Suite.
• Excellent writing skills necessary to facilitate the advanced appeal process

Physical Requirements and Working Conditions:

• This position requires travel, therefore, will be exposed to weather and road conditions.
• Operates all equipment necessary to perform the job.
• Exposed to a normal office environment.

Our Commitment to You:

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate’s job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

Benefits and more

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program