Clinical Appeals Specialist II - RN (REMOTE)
Remote, USA
Full-time
Posted 2025-03-15
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 Computer Skills: Required ? 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
Similar Remote Jobs
Clinical Appeals Specialist II - RN (REMOTE)
Posted on: 19-07-2024 07:10
YouTube Moderator Job, YouTube Jobs $30Hr ? Hiring Now
Posted on: 19-07-2024 07:10
Customer Care Representative, Remote Customer Care - Amazon Pharmacy
Posted on: 19-07-2024 07:10
Customer Service Advocate I
Posted on: 19-07-2024 07:10
Customer service advisor
Posted on: 19-07-2024 07:10
Hobby Lobby Jobs Working From Home, Beginner Remote Jobs
Posted on: 19-07-2024 07:10
Personal Assistant - Work From Home
Posted on: 19-07-2024 07:10
Remote WFH Full Time Administrative assistant - Typing - Part Time...
Posted on: 19-07-2024 07:10
YouTube content Moderator Job (Remote)
Posted on: 19-07-2024 07:10
Social Media Manager 20-25 Hours per Week (IC-DH)
Posted on: 19-07-2024 07:10
Customer Support Representative
Posted on: 27-08-2024 00:00
Data Analyst - Remote | WFH
Posted on: 16-07-2024 18:49
Remote Sales Specialist - Women's Footwear Brand-Dallas Showroom
Posted on: 26-11-2024 06:18
Manager, Operations, Research
Posted on: 27-09-2024 00:00
Remote Contact Center Assistant
Posted on: 31-01-2025 09:57
Business Analyst (Upstream experience needed)
Posted on: 18-09-2024 00:00
Work from Home Customer Service Coordinator - Bank Voice
Posted on: 08-11-2024 05:10
Manager, Sales and Marketing Operations
Posted on: 16-07-2024 18:53
LIVE CHAT SPECIALIST | Remote - Part-Time
Posted on: 05-08-2024 00:00
American Express Virtual Customer Service Jobs ( Customer Care Professional ) @ Latest Job For USA MySmartPros
Posted on: 19-02-2025 06:29