Clinical Appeals Nurse in San Antonio at Parallon

Date Posted: 8/13/2019

Job Snapshot

Job Description

This position works from home/remote.


Parallon believes that organizations that continuously learn and improve will thrive. That’s why after more than a decade we remain dedicated to helping hospitals and hospital systems operate knowledgeably, intelligently, effectively and efficiently in the rapidly evolving healthcare marketplace, today and in the future. As one of the healthcare industry’s leading providers of business and operational services, Parallon is uniquely equipped to provide a broad spectrum of customized revenue cycle services.
 
Job Summary – The Clinical Appeals Nurse is responsible for handling appeals requiring clinical input or interpretation.
 


Duties (included but not limited to):

  • Compose clinical appeal letters to send to payers for denial reconsiderations utilizing documentation, contract language, or voice recordings as applicable
  • Present a concise medical summary within each appeal based on support from the medical record
  • Demonstrate understanding of use of all Medical Necessity software, including but not limited to InterQual©
  • Demonstrate ability to interpret medical payer policy requirements
  • Strong ability to research evidence-based practices
  • Contact appropriate parties (internal and/or external) as needed for additional information to properly formulate the clinical appeal.
  • Determine root cause of each denial and apply company-specific coding for trending and analysis
  • Update the patient account record to identify actions taken on the account
  • Identify problem accounts/processes/trends and escalate as appropriate
  • Complete all required annual training
  • Practice and adhere to the  “Code  of  Conduct”  philosophy  and “Mission  and  Value  Statement”
  • Other duties as assigned

Job Requirements



KNOWLEDGE, SKILLS & ABILITIES

•         Communication - communicates clearly and concisely, verbally and in writing. This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately.
•         Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
•         Interpersonal skills - able to work effectively with other employees, patients and external parties
•         PC skills - demonstrates proficiency in Microsoft Office applications and others as required
•         Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems

•         Technical skills - Professional presentation skills needed to represent facilities in legal issues.
•         Basic skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
•         Clinical skills ability to read and interpret medical records
 


EDUCATION

Associate’s Degree preferred
 


EXPERIENCE

•         At least one year case management experience required
•         Relevant education may substitute experience requirement
 
CERTIFICATE/LICENSE - State RN or LPN License required (Active/Inactive)
 
#ParallonBCOM
 
Parallon/HCA is an equal opportunity workforce and no one shall discriminate against any individual with regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity or expression, genetic information or veteran status with respect to any offer, or term or condition, of employment. We make reasonable accommodations to the known physical and mental limitations of qualified individuals with disabilities.

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