How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.
Work Shift
Day (United States of America)
Job Summary
The Clinical Appeals Process focuses on the review and analysis of medical necessity and authorization payer denials rationales and provides appropriate medical necessity appeal services. The Appeals Nurse will review all denial rationales and case-specific medical records for compliance, accuracy and completeness in accordance with departmental policies and regulations, medical necessity criteria set, payer regulations and other contractual requirements. The appeal nurse will work in conjunction with the UM medical director in constructing appeal letters as appropriate. Job Requirements: Review payer denial response letters in comparison to medical records Prioritize denials based on expiration dates and dollar amount Communicate with all responsible parties regarding missing or insufficient medical documentation Make referrals to Medical Director for physician level reviews Review medical documentation for adherence to Medicare and other payer guidelines relating to inpatient or outpatient services and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided Document UM team involvement and appeal process in star and UM denial module Collect data on trends and communicate to the appropriate hospital departments including the manage care team for JOC engagement. Partner with other hospital/health system team members to eliminate unfavorable trends Work with department manager to orient an onboard new team members Perform other related duties as required
Core Responsibilities And Essential Functions
Review payer denial response letters in comparison to medical records * Prioritize denials based on expiration dates and dollar amount * Communicate with all responsible parties regarding missing or insufficient medical documentation * Make referrals to Medical Director for physician level reviews * Review medical documentation for adherence to Medicare and other payer guidelines relating to inpatient or outpatient services and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided * Document UM team involvement and appeal process in star and UM denial module * Collect data on trends and communicate to the appropriate hospital departments including the manage care team for JOC engagement. Partner with other hospital/health system team members to eliminate unfavorable trends, * Perform other related duties as required * Work with department manager to orient an onboard new team members Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct.
Required Minimum Education
At least a 2 year degree in nursing Required and Bachelor's Degree or above Preferred
Required Minimum License(s) And Certification(s)
All certifications are required upon hire unless otherwise stated.
- Reg Nurse (Single State) or RN - Multi-state Compact
Additional License(s) And Certification(s)
Required Minimum Experience:
Minimum 3 years experience as a case manager, discharge planner, utilization review nurse Required and Minimum 3 years experience as a staff nurse in an acute care setting Required
Required Minimum Skills
Proficient in typing Experience with Microsoft Office suite Ability to learn and understand various clinical software applications Strong clinical judgment and multitasking ability Excellent problem-solving skills Self-motivation and ability of working independently with limited supervision and structure Excellent interpersonal, verbal, and written communication skills
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