Clinical Appeals Nurse

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🔥 16 hours ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

⏰ Full Time

🟠 Senior

🔴 Lead

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Jefferson

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

At Jefferson, we’re more than 65,000 people strong, united in our mission to deliver the highest-quality compassionate care and education across the greater Philadelphia region, Lehigh Valley, Northeastern Pennsylvania, and southern New Jersey. With 32 hospital campuses, we are a nationally ranked leader not just advancing healthcare—we’re shaping healthier communities, pioneering groundbreaking research, and educating tomorrow’s leaders.

📋 Description

• Reviews payor denials and audits for potential lost revenue • Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity • Functions as a hospital liaison with external third-party payors to appeal denied claims • Works closely with Physician advisor team to facilitate appeals to payors • Monitors and reports payor trends to management team • Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor • Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor • Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials • Contacts insurance companies and conducts appeals via telephone or email • Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights • Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors • Ensures that all appeals are sent to the correct payor within the appeal guidelines • Ensures compliance with regulatory and accrediting requirements • Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor • Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable

🎯 Requirements

• Bachelor’s Degree Nursing or Specialized Diploma • 10 years of clinical or case management/utilization review experience • Ability to read medical charts and identify deficiencies in documentation content • Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes • Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures • Knowledge of coding for payment of claims • Insurance knowledge of payors and their unique rules • Epic workflow experience with notes in account history and WQ workflows • Intermediate Excel and MS Word experience • Must complete RCE Training and pass test with 80% or better • RN - Licensed Registered Nurse_PA - State of Pennsylvania

🏖️ Benefits

• medical (including prescription) insurance • supplemental insurance • dental insurance • vision insurance • life and AD&D insurance • short- and long-term disability • flexible spending accounts • retirement plans • tuition assistance • tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service