phrn Clinical denials reviewer / interqual inpatientOmega Healthcare Management Services Inc.

Job Purpose
 
A Clinical Appeals Nurse Specialist is responsible in understanding and analyzing the denials of insurance claims or of coverage for medical treatments or procedures at a healthcare facility and determine whether the denial was warranted or whether to move forward with an appeal.  An appeal is defined as formal, specific, account-level communication issued to a payer to request reconsideration of previously denied services. Communication may be presented in the form of a letter, phone call, online system entry, or other direct payer communication. When services are provided and subsequently denied by insurance companies, all reasonable efforts must be taken to overturn the denial and secure proper reimbursement.
 
Job Duties and Responsibilities for Clinical Appeals Nurse Specialist:
Access account from appropriate work queue and mark account worked to make sure it will not be assigned to another reviewer
Review activity summary, documentation, and correspondence to obtain notes related to the denial
Review for additional information, such as insurance card, face sheet, detailed bill, Explanation Of Benefits, UB04, auth approval, denial letter
Review claim and billing history to isolate any denials related to coding, billing, timely filing, missing or incorrect information
Check and note the ff information:
Diagnosis Codes, Proc Codes, Payer Name, Denial Code, Authorization,     Bill type, date billed, corrected claims
Identify root cause of the denial
Work on Medical Necessity and No Authorization denials , and Untimely filing only
Review medical records and obtain necessary information to support medical necessity
ER, H&P, Physician Orders, Consulatations, Operative Report, Coding Summary, Discharge Summary, Labs, Radiology, MAR, Outside Medical Records, Nurses Notes
Utilize Interqual to run assessment or review for Inpatient Medical Necessity
Compose appeal letter if appealing the denial
Consider the following when selecting the right template:
Type of denial
Is it a full or partial denial
Appeal level being completed
Was InterQual met or not
Is the denial Inpatient or Outpatient
Does payer have contract language
Are there payer specific considerations
Complete the appeal letter
Write clinical summary
Include presenting symptoms, diagnostics, reason for admission, treatment intervention, hospital course, patient disposition and condition at disposition
Include Day by Day clinical progress to support the LOC being appealed or each denied day
Apply contract language, benefits and covered services in researching and deciding the outcome of appeals
Upload and send the letter to the correct fax number/address or Portal
Document activity in the client systems
Required Skills:
Ability to identify complex problems and reviewing related information to develop and evaluate options
Experience with general computer software (Internet, Word, Outlook, PDF required)
Proficiency to learn new software programs quickly
Excellent customer service skills: communicates clearly and effectively
Communicating effectively in writing as appropriate for the needs of the audience
Professional and effective interaction skills with co-workers, clients, providers, and vendors
Proven ability to work well individually and as a team member
Strong attention to detail
Ability to follow company and account-specific standard operating procedures and policies
Ability to adapt to constantly changing environment
Ability to prioritize and organize multiple tasks by remaining focused and quality-driven at all tasks at hand
Ability to remain organized with multiple interruptions
Ability to make decisions independently without bypassing any company and account-specific standard operating procedures and policies
Ability to comfortably receive constructive feedback
Advanced Typing skills of at least 50WPM
Ability to evaluate and check written text for grammatical and typographical error.
Possess strong reading and scanning skills.  
Prioritize multiple tasks, work efficiently within time constraints and deadlines and handle stressful situations.
Required Experience (PHRN):
Must be a PH Registered Nurse with min 2 years of clinical nursing or case management experience
Minimum of 1 year bedside care experience in an acute setting (Clinics are not included)
Minimum 1 year experience in clinical appeals for Inpatient Denials/UR for Inpatient and Continued Stay Reviews
Must have an experience in using Interqual for atleast 1 year