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Cleveland Clinic



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Health Care-Cleveland Clinic
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Denials/Appeals Nurse - PRN Job

Denials/Appeals Nurse

Reference Title
HR Use Only: Denials/Appeals Nurse - PRN
Hospital: Cleveland Clinic Main Campus & Family Health Centers
Job Code: F99975
Pay Grade: 12
Schedule: PRN
Shift: Days
Hours: 8am-5pm
Job Details: - Registered Nurse (RN)
- 3-5 years clinical experience required

Position will be supporting the Payor/Denial Team !!!

Summary: Supports denials, appeals and compliance activities within the Payor Audit & Clinical Denials Management Department. Conducts audits to assure activities conform with regulatory requirements. Supports policy development, implementation and staff education. Participates in the Revenue Cycle committee. Supports managed care activities; appeal documentation and defense process. Works with the multidisciplinary team to evaluate and improve the denial management, documentation and appeal process. Job Responsibilities: Coordinates denial appeal follow-up; analyzes provided clinical documentation, criteria application outcome, physician input, physician advisor input and complete review of medical record. Assures action is taken with appeal time frames to reverse denial. Serves as a liaison of Patient Financial Services for continued appeal process. Supports development of performance improvement strategies in response to identified patterns. Expert in the application of medical necessity review criteria tool ( Milliman and/or InterQual). Assists in training new staff on accurate usage of criteria tools, provides training updates and training on annual criteria releases. Assures Care Management is utilizing criteria tool to maximum benefit. Demonstrates extensive knowledge in the use of multiple hospital systems. Ensures compliance standards are met with required elements and provides feedback to the management team. Contributes to peer review process. Participates in interrater reliability testing. Designs Physician and Care Manager documentation improvements and develops the appeal defense process. Designs and provides follow-up education to Care Management regarding denial trends. Works cooperatively to review, evaluate and improve the denial appeal process and establish a system-wide uniform process. In a positive and successful fashion, identifies, creates, supports, monitors, enhances, and reports compliance activities within the Department. Supports development of performance improvement strategies in response to identified patterns and trends involving various payors (government and non government) Serves as a member on Revenue Cycle committees. Other duties as assigned.

Education: BSN or Bachelor's Degree in related healthcare field preferred. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served. Must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and PC skills. Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement.

Experience: Minimum 3 to 5 years Care Management or Utilization Management experience which would include acute med/surg experience required. Must have expertise with Interqual and Milliman disease management ideologies. In-depth familiarity with third party billing requirements and regulations, billing documentation requirements preferred.

Licensure/Certification/Registration: Licensed Registered Nurse in the State of Ohio. Certification in Case Management preferred. InterQual certification a plus.

Physical Requirements: Manual dexterity to operate office equipment. Requires extended periods of standing, walking and sitting. Normal or corrected vision and hearing to normal range. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work.

Category: Managerial/Professional/Physician

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