Clinical Appeals Nurse in Orange Park, FL at Parallon

Date Posted: 5/17/2018

Job Snapshot

Job Description

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
• 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

• State RN or LPN License required (Active/Inactive)
• Minimum of Associate's degree required

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