Clinical Appeals Specialist RN - Revenue Integrity (1.0 FTE)
Description
Posted wage ranges represent the entire range from minimum to maximum. For jobs with more than one level, the posted range reflects the minimum of the lowest level and the maximum of the highest level. Some positions also offer additional premiums based on shift, certifications or degrees. Job offers are determined based on a candidate's years of relevant experience, level of education and internal equity.
Job Summary:
Responsible for the review and appeal of clinical claim denials and audit determinations for the hospital, including inpatient status disputes and medical necessity denials. Utilizes clinical expertise to interpret documentation and write appeals that utilize nationally recognized criteria such as payer-specific guidelines. Analyzes trends and collaborates with internal and external partners to identify opportunities to recover and retain reimbursement by improving processes.
Primary Duties:
- Responsible for the review and resolution of clinical claim denials and audit determinations.
- Applies clinical expertise and judgment to determine the medical necessity of services billed and compliance with payer policies and guidelines.
- Develops and writes appeal rationales that are supported by medical record documentation and nationally recognized clinical criteria.
- Interprets and applies payer specific policies, guidelines, and contract terminology to develop clinical rationale to support medical necessity of services provided, patient status determinations and readmission reviews.
- Coordinates with Medical Director(s) to clarify medical determinations or clinical rationale.
- Analyzes trends from audits and denials and presents to stakeholders for education and process improvement. Assists with the development of reports as needed to investigate denial issues.
- Collaborates with Care Management to align clinical criteria and definitions from admission through appeal in comparison with payer guidelines and reduce denials.
- Participates in the Audit & Denials Committee along with other key stakeholders.
- Maintains and continually enhances clinical skills, staying current with changes in guidelines and regulations.
- Performs other duties as assigned.
License, Certification, Education or Experience:
REQUIRED for the position:
- Bachelor’s degree in Nursing or related healthcare field.
- 5 years of clinical experience, including 3 years in utilization review, hospital case management, or clinical appeals.
- Experience with payer audits, authorization review processes, and/or claim denials.
- Licensed as a Registered Nurse (RN) in the State of Washington.
- Knowledge of MCG (fka Milliman), InterQual, or other admission guideline tools.
- Strong written and verbal communication skills.
- Demonstrated attention to detail.
- Ability to interpret regulatory guidance, contract language, and payer clinical policies.
DESIRED for the position:
- Epic EMR experience.
- Ability to work independently and productively in a remote work environment.
- General knowledge of healthcare revenue cycle including familiarity with reimbursement methodology, charge capture, and billing processes.
Benefit Information:
Choices that care for you and your family
Choices that care for you and your family
At EvergreenHealth, we appreciate our employees’ commitment and contribution to our success. We are proud to offer a suite of quality benefits and resources that are comprehensive, flexible, and competitive to help our staff and their loved ones maintain and improve health and financial well-being.
- Medical, vision and dental insurance
- On-demand virtual health care
- Health Savings Account
- Flexible Spending Account
- Life and disability insurance
- Retirement plans 457(b) and 401(a) with employer contribution)
- Tuition assistance for undergraduate and graduate degrees
- Federal Public Service Loan Forgiveness program
- Paid Time Off/Vacation
- Extended Illness Bank/Sick Leave
- Paid holidays
- Voluntary hospital indemnity insurance
- Voluntary identity theft protection
- Voluntary legal insurance
- Pay in lieu of benefits premium program
- Free parking
- Commuter benefits
- Cafeteria & Gift Shop Discount
View a summary of our total rewards available to you as an EvergreenHealth team member by clicking on the link below.