Clinical Appeals Specialist RN

Evergreen Health; Kirkland (WA); Remote; USD 125,000 - 150,000; Full time

Job summary

An established industry player is seeking a detail-oriented Registered Nurse to manage clinical claim denials and audits. This remote role requires expertise in interpreting clinical documentation and writing effective appeals. You will collaborate with various stakeholders to enhance processes and reduce denials, making a significant impact on the healthcare revenue cycle. The ideal candidate will possess strong communication skills and a solid understanding of payer policies. Join a supportive team that values your contributions and offers a comprehensive benefits package to ensure your well-being.

Benefits

Medical, Vision, and Dental Insurance

Health Savings Account

Flexible Spending Account

Tuition Assistance

Paid Time Off

Retirement Plans

Paid Holidays

Commuter Benefits

Free Parking

Life and Disability Insurance

Qualifications

• Licensed RN in Washington with clinical experience in health insurance.
• Strong communication and organizational skills are essential.

Responsibilities

• Review and resolve clinical claim denials and audit determinations.
• Develop appeal rationales supported by medical documentation.
• Collaborate with stakeholders to improve processes and reduce denials.

Skills

Clinical Expertise

Written Communication

Verbal Communication

Detail-Oriented

Organizational Skills

Regulatory Guidance Interpretation

Decision Making

Payer Audits Experience

Education

Registered Nurse License in Washington

Bachelor's Degree in Healthcare

Tools

Epic EMR

MCG (Milliman)

InterQual

Job description

Wage Range: $43.26 - $69.22 per hour

Posted wage ranges represent the entire range from minimum to maximum. For jobs with more than one level, the posted range reflects the minimum of the lowest level and the maximum of the highest level. Some positions also offer additional premiums based on shift, certifications or degrees. Job offers are determined based on a candidate's years of relevant experience, level of education and internal equity.

Please Note: This is a remote position; however, due to our pay practices, qualified candidates must reside in the State of Washington. While work is remote, candidates must have reliable broadband internet and personal cell phone service. Remote work may involve regular operations during Pacific Time business hours and participation in online training

Job Summary
Responsible for the review and appeal of clinical claim denials and audit determinations for the hospital. Utilizes clinical expertise to interpret documentation and write appeals that utilize nationally recognized criteria to support the medical necessity of services billed. Understands and references Medicare and commercial payer policies to support appeal rationales. Communicates and coordinates effectively with all levels of the organization and payer representatives. Analyzes trends and collaborates with internal and external partners to identify opportunities to reduce denials by improving processes.

Primary Duties:
1. Responsible for the review and resolution of clinical claim denials and audit determinations.
2. Applies clinical expertise and judgment to determine the medical necessity of services billed and compliance with payer policies and guidelines.
3. Develops and writes appeal rationales that are supported by medical record documentation and nationally recognized clinical criteria.
4. Interprets and applies payer specific policies, guidelines, and contract terminology to develop clinical rationale to support medical necessity of services provided, patient status determinations and readmission reviews.
5. Coordinates with Medical Director(s) to clarify medical determinations or clinical rationale.
6. Analyzes trends from audits and denials and presents to stakeholders for education and process improvement. Assists with the development of reports as needed to investigate denial issues.
7. Collaborates with Care Management to align clinical criteria and definitions from admission through appeal with payer guidelines to reduce denials.
8. Participates in the Audit and Denials Committee along with other key stakeholders.
9. Maintains and continually enhances clinical skills, staying current with changes in guidelines and regulations.
10. Performs other duties as assigned.

License, Certification, Education or Experience:

REQUIRED for the position:
u25CF Licensed as a Registered Nurse (RN) in the State of Washington.
u25CF Experience in clinical, health insurance, coding/claims review, or case management setting.
u25CF Strong written and verbal communication skills.
u25CF Must be highly detail oriented.
u25CF Must have superior organizational skills.
u25CF Ability to understand and interpret regulatory guidance, contract language, and payer specific policies.
u25CF Ability to make decisions with respect to his/her delegated responsibilities.
u25CF Experience with payer audits, authorization review processes, and/or claim denials.

DESIRED for the position:
u25CF Bacheloru2019s degree in a healthcare or related area.
u25CF 3 years of clinical nursing and/or case management experience
u25CF Knowledge of MCG (fka Milliman), InterQual, or other admission guideline tools.
u25CF Epic EMR experience.
u25CF General knowledge of healthcare revenue cycle including familiarity with reimbursement methodology, charge capture and billing processes.

Benefit Information:u00A0
Choices that care for you and your family

At EvergreenHealth, we appreciate our employeesu2019 commitment and contribution to our success. We are proud to offer a suite of quality benefits and resources that are comprehensive, flexible, and competitive to help our staff and their loved ones maintain and improve health and financial well-being.

u2022 Medical, vision and dental insurance
u2022 On-demand virtual health care
u2022 Health Savings Account
u2022 Flexible Spending Account
u2022 Life and disability insurance
u2022 Retirement plans (457(b) and 401(a) with employer contribution)
u2022 Tuition assistance for undergraduate and graduate degrees
u2022 Federal Public Service Loan Forgiveness program
u2022 Paid Time Off/Vacation
u2022 Extended Illness Bank/Sick Leave
u2022 Paid holidays
u2022 Voluntary hospital indemnity insurance
u2022 Voluntary identity theft protection
u2022 Voluntary legal insurance
u2022 Pay in lieu of benefits premium program
u2022 Free parking
u2022 Commuter benefits

View a summary of our total rewards available to you as an EvergreenHealth team member by clicking on the link below.

EvergreenHealth Benefits Guideu00A0

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