Clinical Appeals Nurse
United StatesFull-TimeMiddle
Salary77,905 - 116,858 USD per year
Apply NowOpens the employer's application page
Job Details
- Experience
- Minimum (2) years' clinical nursing experience; Minimum 1 year utilization management or appeals / denials experience
- Required Skills
- Microsoft ExcelEHR
Requirements
- Current, active, and unrestricted California LVN or RN license.
- Minimum of 2 years of clinical nursing experience (med/surg, case management, or acute care).
- Minimum of 1 year of utilization management or appeals/denials experience in a managed care or health plan environment.
- Knowledge of ICD-10 and CPT coding.
- Knowledge of CMS (Chapter 13) guidelines and regulations.
- Proficiency in clinical case management systems or EHR platforms.
- Proficiency in Microsoft Word, Excel, and Outlook.
- Advanced problem-solving and reasoning skills to collect data, draw valid conclusions, and implement resolutions.
- Effective written and oral communication skills.
- Ability to perform mathematical calculations and simple statistics.
- Completion of an accredited LVN or RN nursing program.
Responsibilities
- Review and prepare appeal requests for medical necessity and refer cases requiring MD approval to a Medical Director.
- Independently apply evidence-based clinical criteria such as Milliman, InterQual, and CMS NCD/LCD to conduct objective medical necessity reviews.
- Maintain established turn-around time (TAT) goals for appeal processing and manage expedited requests to ensure compliance.
- Coordinate peer-to-peer conversations to maintain professional rapport with providers, physicians, staff, and patients.
- Verify eligibility, benefit coverage, and the accuracy of ICD-10 and CPT coding when evaluating appeals.
- Contact requesting providers to obtain necessary medical records, orders, and documentation.
- Review appeal denials for appropriate guidelines and language and prepare formal denial letters.
- Maintain complete, auditable call and case notes in the system and participate in regulatory audits when required.
View Full Description & ApplyYou'll be redirected to the employer's site
