AR Clinical Appeals Nurse

Overview:

WE ARE HIRING!
Location: 250 E Liberty Street Louisville, KY 40202 

About UofL Health 
UofL Health is a fully integrated regional academic health system with nine hospitals, four medical centers, Brown Cancer Center, Eye Institute, nearly 200 physician practice locations, and more than 1,000 providers in Louisville and the surrounding counties, including southern Indiana. Additional access to UofL Health is provided through a partnership with Carroll County Memorial Hospital.  Affiliated with the University of Louisville School of Medicine, UofL Health is committed to providing patients with access to the most advanced care available. This includes clinical trials, collaboration on research and the development of new technologies to both save and improve lives. With more than 13,000 team members – physicians, surgeons, nurses, pharmacists and other highly-skilled health care professionals, UofL Health is focused on one mission: to transform the health of communities we serve through compassionate, innovative, patient-centered care. For more information on UofL Health, go to www.uoflhealth.org.

Job Summary:

The Clinical Appeals Nurse plays an integral role in the recovery of denied reimbursement for hospital services rendered to a patient by providing a comprehensive review of a members’ clinical information and comprising a verbal or written response depicting why the services were medically necessary. This position will be responsible for claim denials as well as pre or post-payment audits from insurance carriers or designated third part vendors. Responsible for the identification, mitigation, and prevention of clinical denials including medical necessity and authorization issues.

This position will maintain reporting and collaborate with the Payor Relations and Contracting Department during contract negotiations and settlements on denial issues and payment variances impacting payment from third party payers for consideration.

• Ensures clinical interventions are appropriate for the admitting diagnosis and reflects the standard of care as defined by the medical staff and health system.
• Utilizes clinical knowledge and defined standards of care to proactively identify inappropriate admit status based on identified criteria (MCG and Interqual Criteria).
• Communicates with physicians and multidisciplinary health system team members to effectively utilize all available resources to ensure a strong and efficient appeal is submitted.
• Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to the billed charges.
• Research commercial and governmental payor policies, regulations, and clinical abstracts related to claims payment to evaluate and appeal denied claims.
• Understanding of patient accounting documents – UB04, EOB
• Perform retrospective authorization requests for services already performed as needed.
• Supports billing staff by reviewing accounts as requested before claim submission to prevent clinical denials.
• Supports global denial prevention and mitigation efforts throughout the health system by attending denial prevention meetings and/or payer representative meetings.

MINIMUM EDUCATION & EXPERIENCE

• Active, unrestricted registered clinical license required
• 3-5 years of clinical experience required
• Experience with appeals and/or denial processing preferred
• Clinical nursing experience working in a hospital setting – ER, Critical Care, or Diagnostic Services preferred
• CCM (certified case manager), CPUM (certified professional in utilization management) or other relevant certification is preferred

KNOWLEDGE, SKILLS, & ABILITIES

• Critical thinking skills
• Strong oral and written communication skills
• Advanced Microsoft Office knowledge
• Ability to foresee projects from start to finish