Clinical Appeals Nurse RN - HOU in Houston, TX at Parallon

Date Posted: 3/15/2018

Job Snapshot

  • Employee Type:
  • Location:
    8101 West Sam Houston Parkway South
    Houston, TX
  • Job Type:
    Health Care, Nurse
  • Experience:
    At least 1 year(s)
  • Date Posted:

Job Description

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

  • Associate’s Degree preferred


  • At least one year case management experience required
  • Relevant education may substitute experience requirement

Certificate/License - State RN or LPN License required (Active/Inactive)