Nurse Specialist – Clinical Denials and Appeals

Role Overview

• Responsible for reviewing the claims denied and carrying out the appeals process appropriately and in a timely manner
• Identifies and works denials, responding to the denial reason and resubmitting any information needed to the payor
• Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing the clinical documentation, assessing options and completing next steps
• Submit retro-authorizations in accordance with payor requirements in response to authorization denials
• Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals.
• Write and submit written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language
• Document all actions taken and follow-up timely as needed related to resolving denials and appeals with third-party payers in a timely manner
• Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Complies with state and federal regulations, accreditation/compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA

Requirements

• At least 1 year of clinical appeal writing experience
• Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years if ICU experience
• Associate Degree in Nursing (ADN) or Diploma in Nursing
• Must be Registered Nurse with an active USRN license
• Proficiency in using InterQual or MCG clinical guidelines
• Broad Knowledge of U.S. Government Programs and Insurance Regulations
• Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech
• Case management or clinical appeals or clinical denials certification (ACMA) is preferred.
• Proficiency with Microsoft office suite (Excel, Word, PowerPoint, Outlook, SharePoint)

Benefits

• Medical, dental and vision coverage
• Employee stock purchase plan
• 401(k) plan with a generous employer match
• Paid Time Off policy
• Paid parental leave and adoption assistance
• Free annual health screenings and coaching