USRN with interqual inpatient experience onsite ( lahug cebu)Omega Healthcare Management Services Inc.

 
Required Experience (USRN)
 
1.Must be a US Registered Nurse
2.Minimum of 1 year bedside care experience in an acute setting ( clinics are not included)
3.Minimum of 1 year experience in clinical appeals for Inpatient Denials/ UR for interqual and continued stay reviews
 
 
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
o   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
o   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
o   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
o   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