Clinical Appeals Specialist II - RN (REMOTE)

Job Description

(Full Time, Remote)

The Clinical Appeals Specialist II - RN supports CHS hospitals with appeals of health plan medical necessity, authorization and level of care denials. Reviews all assigned denials, obtains additional information as needed and files appeals necessary to resolve payor issues on denied claims. Forwards denial information on inpatient claims to appropriate department or personnel and oversee maintenance and upkeep of denial logs, and documents as required. Assist other business office personnel with clinical guidance on billing and reimbursement issues as needed as well as act as resource to facility clinical departments on areas of denial prevention and resolution.

As a Clinical Appeals Specialist II - RN at CHS Shared Service Center - Nashville, you’ll play a vital role in supporting our purpose to help people get well and live healthier by providing safe, quality healthcare, building enduring relationships with our patients, and providing value for the people and communities we serve. Our team members enjoy a robust benefits package including health insurance, flexible scheduling, 401k and other elective benefit programs.

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 related departments as needed.
• Track and manage clinical denials using current tools (manuals, training programs).
• Identify patterns and trends in denials; communicate to appropriate persons.
• Maintain documentation regarding all payor resources regarding denials and appeals processes.
• Understand and apply CHS 10-Step 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 when dealing with patients, families and/or significant others, outside vendors, coworkers, and physicians.
• Provide education to staff as appropriate.
• Document all actions accordingly by documentation standards within Artiva, HMS and other business office systems as required.
• Be familiar with policy and procedure manuals and other reference materials.
• Ensure confidentiality of all patient accounts by following HIPAA guidelines
• Perform additional duties as assigned or requested.
  
  

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge/Abilities

Required

• Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures.
• Understanding of the revenue cycle and the responsibility and goals of each area
• Must be able to interact with all levels of hospital administration, physicians and other healthcare team members they impact the revenue cycle
• Must be able to follow directions and perform 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

Required

Computer Skills:

• Microsoft office
  
  

Education/Experience

Required

• Must have diploma/degree from an accredited school of nursing
• 5 years of clinical nursing experience.
• Certificates and Licenses: Current RN license to practice in state
  
  

Preferred

• Utilization review and/or case management experience
  
  

We know it’s not just about finding a job. It’s about finding a place where you are respected, valued and where your work is purposeful and fulfilling. A place where your talent is recognized, professional development is encouraged and career advancement is possible.

Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 71 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.