Role OverviewThe Clinical Appeals Review Nurse reviews and analyzes denied/downgraded MS-DRG and APR-DRG and APC accounts received from all types of payers (e.g., Medicare, Commercial, and Third Party). The Nurse will render determination on whether the denied/downgraded account is appealable based on the standards of each client.
What You Will Do
Conduct secondary quality reviews of clinical appeal letters to ensure accuracy, clinical soundness, and compliance with coding, payer, and regulatory requirements prior to submission. Perform efficient analysis of denied claims, pinpointing reason for denial and potential for success of appeal.
Why It Might Be a Fit
The Clinical Appeals Review RN DRG will provide either a reasoned explanation why no appeal can be written, or a detailed appeal letter based on current coding and regulatory guidelines and clinical criteria. In either case the Nurse will then track and trend MRI defined denial root causes for each specific denial.
Requirements
- Registered Nurse (BSN preferred)
- CCS, CPC, CCDS, or RHIT Certification is required
- Graduate of an accredited College or University, BSN is preferred
- 5+ years of clinical experience in Hospital inpatient and outpatient departments
- 2+ years of clinical appeals/denials writing experience
- Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG and APC medical records and accounts received from payers (e.g., Medicare, Commercial, and Third Party)
- Experience in a variety of Electronic Medical Records (EMR) Systems, i.e. (3M, Nuance, Epic, etc)
Benefits
- Medical, Dental, and Vision Insurance
- Phone and Internet Stipend
- Company-Paid Life Insurance
- 401(k) Retirement Plan with Company Match
- Paid Time Off
- Seven Company-Observed Holidays
- Two Floating Holidays for Personal Observance
- Professional Development Opportunities
- Employee Recognition Programs
- Remote Work Environment
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