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Clinical Appeals Nurse RN - Work From Home in Houston at Parallon

Date Posted: 12/24/2018

Job Snapshot

Job Description

Job Summary:
The Clinical Appeals Nurse is responsible for handling appeals requiring clinical input or interpretation. (This is a full-time work from home opportunity).

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
  • Other duties as assigned

Job Requirements

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)
 
Work from Home Requirements
• Designated Work Area: Remote Workers are required to maintain a separate, designated work area at home
• Minimum Technical Specifications Home Internet Connectivity: Download and Upload -10Mbps