Job Attributes

Work Schedule/Shift

Days

Job ID

5000409892406

Req. No

70030775

Job Title

RN, Clinical Appeals - Patient Financial Support

Region

CHRISTUS Trinity Mother Frances

Category

Registered Nurse (RN)

Division

Not Defined

Company

CHRISTUS Health

Travel

None

Facility

CTMF Health System-38300

Address

1315 Doctors Dr
Tyler, TX  75701
US

Type

Full Time

Apply Now RN, Clinical Appeals - Patient Financial Support Job in Tyler

Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility. The RN Clinical Appeals Nurse will perform duties aimed at denials prevention and billing compliance.

A. Education/Skills
  • Graduate of an accredited School of Nursing with a Bachelor's degree in nursing is preferred; associates degree in nursing accepted with strong clinical experience.
  • Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task
  • Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff).
  • Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomes
  • Assertive and diplomatic communication, proven ability to function on a multidisciplinary team.
  • Excellent organizational skills including effective time management, priority setting and process improvement.

 B. Experience

  • Two to four years of Utilization Review/Case Management experience strongly preferred.
  • Two to three years' experience in the denial and appeal process strongly preferred (clinic or hospital)
  • Experience with managed care, governmental and/or RAC appeals strongly preferred.
    • Knowledgeable of InterQual and Milliman Care Guidelines (MCG) medical necessity criteria
  • Understanding of Medicare, Medicaid and third party reimbursement methodologies.
  • Computer experience in Microsoft Office (Word and Excel).

 C. Licenses, Registrations, or Certifications:

  • Current RN Nursing license
  • Interqual and/or MCG certification preferred. Case Management certification preferred
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