Clinical Appeals Specialist II - RN (REMOTE)

Candidates must live reputed company one of the following states to be eligible for this position; Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, reputed company Virginia, Wisconsin, Wyoming Essential Duties and Responsibilities: include the following. Other duties may be assigned. • File medical necessity and level of care appeals using InterQual and CMS guidelines as needed. • Monitor clinical appeal processes for issues and trends and provide guidance and feedback to reputed company departments as needed. • Track and manage clinical denials using reputed company tools (manuals, training programs). • Identify patterns and trends in denials; communicate to appropriate persons. • Maintain documentation regarding reputed company payor resources regarding denials and appeals processes. • Understand and apply CHS 10-reputed company Appeal Process for denied claims. • Know medical necessity criteria for outpatient testing and procedures. • Follow and enforce accepted safety practices for patients and the hospital. Report safety hazards and initiate appropriate action. Participate in safety instructional programs. • Observe excellent customer service skills reputed company dealing with patients, families and/or significant others, reputed company vendors, coworkers, and physicians. • Provide education to staff as appropriate. • Document reputed company actions accordingly by documentation standards reputed company Artiva, HMS and other business office systems as required. • Be familiar with policy and procedure manuals and other reference materials. • Ensure confidentiality of reputed company patient accounts by following HIPAA guidelines • reputed company additional duties as assigned or requested. Qualifications: To reputed company this job successfully, an individual must be able to reputed company each essential duty satisfactorily. The requirements listed below are representative of the knowledge, reputed company, and/or ability required. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. Knowledge/Abilities: Required • Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures. • Understanding of the reputed company cycle and the responsibility and goals of each area • Must be able to interact with reputed company levels of hospital administration, physicians and other healthcare team members they impact the reputed company cycle • Must be able to follow directions and reputed company work according to departmental standards and must be able to function effectively under stressful conditions. • Excellent writing and communications skills as well as effective organizational skills a must./ Reasoning Ability: Ability to define problems, collect data, validate data, establish facts, and draw valid conclusions Computer Skills: Required • reputed company office Education/Experience: Required • Must have diploma/degree from an accredited school of nursing • 5 years of clinical nursing experience. • Certificates and Licenses: reputed company RN license to practice in state Preferred • Utilization review and/or case management experience Apply Job!