Clinical Appeals Nurse - Work from Home in Largo, FL at Parallon

Date Posted: 7/18/2018

Job Snapshot

Job Description

The Company: Parallon Business Solutions is a subsidiary of Hospital Corporation of America and HCA West Florida. We provide a variety of services including revenue cycle, supply chain management, and workforce management to 1,400 hospitals and 11,000 non-acute care providers, including ambulatory
surgery centers, physician practices and alternate care sites. We have been voted one of the top employers in Florida for 8 years in a row, and are known for taking the best care of clients and employees alike.
● Our culture fosters an environment of continuous growth and professional development.
● Parallon was named a “Top 100 Company to Watch for Remote Jobs in 2016” by FlexJobs.
● We believe in rewarding our employees with a healthy work/life experience, our employees are rewarded with comprehensive health and wellness benefits, financial and retirement planning support, and time away from work options.


Job Summary – The Clinical Appeals Nurse is responsible for handling appeals requiring clinical input or interpretation.
Supervisor –Appeals Manager
Supervises – not applicable
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

• 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 utilization review experience required

- One or more year of InterQual experience

- Relevant education may substitute experience requirement
CERTIFICATE/LICENSE - Florida RN or LPN License required 
Requires prolonged sitting/standing, some bending, stooping, walking and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports or other information. Requires lifting papers/boxes and pushing/pulling up to 25 pounds occasionally. Work is performed in an office environment or hospital setting. Work may be stressful at times. Contact may involve dealing with angry or upset people. Staff must remain flexible and available to provide staffing assistance for any/all disaster or emergency situations.