Virtual Clinical Appeals Nurse in Nashville, TN at Parallon

Date Posted: 3/5/2018

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



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)