Clinical Denials and Appeals RN

The Remote Clinical Denials/Appeals Nurse will be directly responsible for securing pre-service approvals, and reviewing pre/post service denials, medical necessity review and completing appeals and/or coordinating peer to peer reviews as appropriate. This position will perform all related job duties as assigned. Essential Job Functions: Medical Necessity Reviews Ensure documentation integrity Construct warranted appeals Coordinate pre-service authorization approvals

Conduct comprehensive Denial Root-cause analysis Retrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present to support medical necessity Collaboration with hospital Patient Access and Mid-Revenue Cycle Utilize Evidence -based clinical guideline tool (Milliman ® or InterQual ®) Research and application of regulatory policies to support clinical appeal Telephonic communication with payors, provider, hospital staff and patient/family as necessary to bring the account into resolution. Technical ability to multi-task on various systems, desktop and Microsoft applications while managing inbound calls Working knowledge of basic Coding Guidelines May be required to present oral presentations to client facility or Guidehouse staff and leadership Attention to detail, strong organizational skills and self-motivated. Ability to make decisions and assimilate multiple data sources or issues related to problem solving independently & accurately Ability to work under a timeline/deadline & provide clear & accurate updates to project leader of assignment progress, hours worked & expected outcomes daily Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service