Clinical Denials & Appeals Registered Nurse

Job Description ECU Health About ECU Health Medical Center ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people. Position Summary The appeals nurse is responsible for the timely review of denied claims from all payers related to medical necessity, appropriate setting/status determination, authorizations and appropriate length of stay. Ensures all denied claims are accurately worked and appealed to obtain maximum reimbursement and minimize recoupment. Combines clinical, business and regulatory knowledge and skills to reduce financial risk and exposure caused by concurrent and retrospective denial of payment for rendered services. This position will utilize MCG guidelines, Medicare's 2-midnight rule, and any other payer specific requirement for inpatient, along with the appropriate payer medical policy or NCD/LCD for outpatient services. Medical records may also need to be reviewed for audited claims using the same resources as if the case were denied to prevent recoupment or receive payment related to pre- or post-bill audits. Responsibilities Reviews Medical Record and determines whether each case should be appealed, downgraded, or referred to physician advisors (PAs). Downgrading would occur if PA indicated in notes or no clinical justification noted in medical record. A medical record review may include investigating a patient's medical and treatment history or obtaining external medical records necessary to support the hospital medical record. Write comprehensive, concise appeals, utilizing appropriate screening tools and payer policies such as MCG/LCDs/NCDs, etc. Perform timely medical record audit review for accuracy (retro and prebill). Track all denial/appeal activity, identifying trends and document outcomes. Review response letters from insurance carriers and follow-up as necessary. Minimum Requirements Bachelor of Science in Nursing. 5 years of related work experience within Case Management, Utilization Review, or Clinical Documentation Improvement. In place of a Bachelor's in Nursing, an Associate Degree in Nursing (RN) is acceptable with an accompanying 10 years experience in Case Management, Utilization Review, or Clinical Documentation Improvement. General Statement Share: