Appeals and Grievance Nurse Registered Nurse II - Clinical Appeals - Full Time in Houston, TX

Job Description | Job Attributes

Summary:

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. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. 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.

Responsibilities:

• Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services
• Review governmental contractors response letter in comparison to the medical records
• Communicates with facility regarding missing or insufficient medical documentation
• Review medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided
• Research issues using federal or law, federal regulations, and relevant CMS policies Communicates with members of the healthcare team identifying root causes for potential denials
• Communicates with the CMO/VPMA regarding appeals and obtain signature for appeals
• Assures all discussions and appeals are filed timely
• Completes data entry in the Denial database for tracking, trends, and analysis

Requirements:

Education/Skills

  • Associate's Degree in Nursing

Licenses, Registrations, or Certifications

  • RN License in state of employment or compact

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time


EEO is the law - click below for more information: 

https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at (844) 257-6925.

Apply Now
Current Associate? Click here to apply
Not ready to apply? Join our Talent Pool

Job Attributes

Job ID

209230

Job Title

Appeals and Grievance Nurse Registered Nurse II - Clinical Appeals - Full Time

Job Type

FULL TIME

Schedule / Shift

8AM - 5PM

Job Category

Revenue Cycle

Location

CHRISTUS Ministry System Office
2900 North Loop West
Houston, TX  77092 View on a map

Appeals and Grievance Nurse Registered Nurse II - Clinical Appeals - Full Time

This jobs functionality is being updated, please use the search jobs page and filter by location.