Job detail

Clinical Appeals RN

KPC GLOBAL MEDICAL CENTERS INC.

#HIPAA #Medical Director #Correspondence #Managed Care #Patient Confidentiality #RN License #Regulations #State Requirements #Policy

Quick overview

The Clinical Appeals Nurse investigates and processes medical necessity appeals from members and providers to payers, requiring research into standards, regulations, and policy to overturn or uphold denied claims. This role involves ensuring timely and accurate processing of all denials according to policies and requirements, and preparing cases for Medical Director review when necessary.

Requirements summary

Candidates must possess a current active California RN license and a minimum of two years of experience in a managed care healthcare setting, including two years in Utilization Management. Essential requirements include experience applying payer-specific medical guidelines and proficiency with MCG and/or InterQual guidelines.

Written CommunicationVerbal CommunicationCustomer ServiceHIPAA ComplianceComputer ProficiencyResearchClaim ProcessingUtilization ManagementClinical AppealsMCG GuidelinesInterQual GuidelinesMedical Necessity AppealsMedical Guidelines Application

Job description

SUMMARY

The Clinical Appeals Nurse is responsible for investigating and processing medical necessity appeals from members and providers to payers.
Possesses the ability to conduct research on standards or practice, regulations, and policy relevant to any case.
Responsible for overturning denied claims, upholding the denials and submitting cases to the Medical Director for review.
Possesses the ability to communicate clearly and concisely, both verbally and in writing and utilize computer and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Ensures timely and accurate processing of all denials.
Will ensure that denials are processed according to KPC Policies and meet all Health Plan, Federal and State requirements.
Perform other duties as assigned.

Requirements

Current active California RN license required
Minimum 2 years of experience in a managed care healthcare setting
Minimum 2 years of Utilization Management
Experience with payer specific medical guidelines and how to apply them in an appeal
Experience using MCG and/or InterQual guidelines

Duties and Responsibilities

Conduct and investigate member and provider medical necessity appeals
Review prospective, inpatient, and retrospective medical records of denied services for medical necessity
Ensures appeals and grievances are resolved in a timely manner
Prepare clinical reviews and provides monitoring of cases involving medical decisions and quality of services and care
Generate written correspondence to providers and members to achieve maximum overturn rate
Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received