PRIMARY FUNCTION:

The RN Clinical Appeals Coordinator will partner with physician advisors to ensure medically necessary inpatient denials are appealed, as appropriate, to ensure optimal reimbursement and trend appeals outcome data.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Optimize appeal outcomes of Medicare Advantage, Commercial and Medicaid plans via all available appeal options including, but not limited to peer to peer appeals, secondary appeals, and involvement with IROs

Evaluate and understand inpatient medical necessity appeal options for all federal and commercial payers

Interpret Medical Director notes and summarize into correspondence for provider and/or facility.

Review first and second level appeals for medical necessity, completes a comprehensive medical necessity packet summarizing clinical facts for Physician Advisor review

In collaboration with appeals assistant, provides accountability for status of pending appeals

In collaboration with physician advisor, constructs appeal letters

Partners with Admitting and Billing to ensure optimal appeals processes.

Partners with denial team to ensure optimal denials process was pursued.

Uses data to identify revenue opportunities based on payer determinations, appeals, and outcomes.

Collaborate with Contracting to understand payer-based contracts to leverage available appeal options as appropriate

Identifies system issues that serve as barriers to appeal outcomes. Participates in development and implementation of strategies to remove barriers to increase Inpatient revenue

Prepares reports to identify inpatient appeal processes and outcomes

Provides education to clinical providers, inpatient case management, and inpatient utilization management teams on best practices to avoid denials based on appeals trends

Performs other duties as assigned.

EDUCATION AND EXPERIENCE REQUIREMENTS:

Bachelor's Degree in Nursing required
Registered RN licensed to practice in the State of DE required (Or compact state)
Experience working in Utilization Management and/or Case Management required
Two or more years of denial management experience preferred
Strong medical terminology & clinical awareness
Effective communication, writing, and clinical skills

SPECIAL REQUIREMENTS:

Active RN Delaware license.

WORKING CONDITIONS:
Frequent travel to multiple sites as needed. Occasional exposure to office materials. Normal office environment.