Remote Denials Appeals Nurse—Payer Authorization Expert

Santa Barbara Cottage Hospital; United States; Remote; USD 70,000 - 110,000; Full time

Job summary

Shriners Children’s is seeking an Authorization Denials Appeals Nurse to manage denial appeals by reviewing clinical documentation and determining if retro-authorization is warranted. The appeals nurse will serve as a clinical resource to the Central Authorization Unit and provide peer-to-peer reviews when the payer allows a nurse to participate in the process.

The nurse will write compelling arguments for appealing denials and maintain knowledge of payer criteria.

Qualifications

• 3 years of clinical healthcare/hospital experience.
• Third Party Payor Appeals/Revenue Cycle experience.
• Experience with Utilization Review activities and criteria sets used to determine eligibility for acute care hospitalization.
• Functional knowledge of DRG and CPT coding systems.
• Proficiency in MS Office.
• Active RN License in current State of employment.
• Associate's Degree.

Responsibilities

• Screens denials for possible reconsideration or formal appeal.
• Investigates denials and tracks trends for internal process improvements.
• Prepares and submits appeals per payer guidelines.
• Utilizes clinical knowledge to support administrative appeals and payor requirements.
• Communicates clinical information to Physicians and Medical Directors regarding payer determinations.
• Edits and educates departments on payer changes and denial processes.

Skills

MS Office

Clinical healthcare experience

Utilization Review

Denials analysis

Education

Associate's Degree

RN license (Active in state)

Bachelor's Degree (BSN)

Tools

DRG coding systems

CPT coding systems

Payer guidelines portals

Job description

Shriners Children’s is seeking an Authorization Denials Appeals Nurse to manage denial appeals by reviewing clinical documentation and determining if retro-authorization is warranted. The appeals nurse will serve as a clinical resource to the Central Authorization Unit and provide peer-to-peer reviews when the payer allows a nurse to participate in the process.

The nurse will write compelling arguments for appealing denials and maintain knowledge of payer criteria.