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Appeals and Grievance Nurse Registered Nurse II – PRN


This is a Full-time position in Houston, TX posted August 22, 2021.

Job Description: Description Summary: 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.

Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal servicesReview governmental contractors response letter in comparison to the medical recordsCommunicates with facility regarding missing or insufficient medical documentationReview medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services providedResearch issues using federal or law, federal regulations, and relevant CMS policiesCommunicates with members of the healthcare team identifying root causes for potential denials.Communicates with the CMO/VPMA regarding appeals and obtain signature for appealsAssures all discussions and appeals are filed timelyCompletes data entry in the Denial database for tracking, trends, and analysis Requirements:Graduate of an accredited School of Nursing with a Bachelors degree in nursing or health related field.Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-taskAbility to communicate with multiple levels in the organization (e.g.

managers, physicians, clinical and support staff).Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomesAssertive and diplomatic communication, proven ability to function on a multidisciplinary team.Excellent organizational skills including effective time management, priority setting and process improvement.Two to four years of Utilization Review/Case Management experience.Two-three years experience in the denial and appeal process.Experience with managed care, governmental and/or RAC appeals strongly preferred.Knowledgeable of InterQual and Milliman Care Guidelines (MCG) medical necessity criteriaUnderstanding of Medicare, Medicaid and third party reimbursement methodologies.Computer experience in Microsoft Office (Word and Excel).

Current RN Nursing licenseInterqual and/or MCG certification preferred.

Case Management certification preferred Work Type: Per Diem As Needed

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