Clinical Appeals Nurse

Job not on LinkedIn

🕒 July 30

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

⏰ Full Time

🟠 Senior

🔴 Lead

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👻 Ghost score 32%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Jefferson

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

🏥 Healthcare

📚 Education

Healthcare • Education

Jefferson is a healthcare organization comprising over 65,000 individuals dedicated to providing high-quality compassionate care and education in the greater Philadelphia region, Lehigh Valley, Northeastern Pennsylvania, and southern New Jersey. It operates 32 hospital campuses and is recognized as a leader in healthcare, focusing on innovative research and the education of future healthcare professionals through its 10 colleges and three schools that offer over 200 programs to more than 8,300 students. Additionally, Jefferson provides health coverage to 360,000 members through Jefferson Health Plans and Health Partners Plans, ensuring access to quality care for over 35 years.

📋 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 and the documentation found in the hospital/physician information system • Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor to meet their guidelines • 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 • access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service