Registered Nursing
Case Management Social Services
Full Time
8 Hour Shift
Rancho Mirage, CA
Job #

  • Job Objective: A brief overview of the position.

    • The Clinical Appeal Nurse reviews denied claims and processes appeals to the payer to recover payment for medical necessity, authorization and level of care denials. Reviews all assigned inpatient denials; obtains information as needed to file clinical appeals necessary to recover payer denial of reimbursement on inpatient, outpatient, or observation claims. Communicates clinical denial to appropriate departments and/or personnel for follow up and educational purpose.

  • Reports to

    • Director of Case Management

  • Supervises

    • N/A

  • Ages of Patients

    • All ages

  • Blood Borne Pathogens

    • Minimal/ No Potential

  • Qualifications

    • Education

      • Required: BSN or MSN or enrollment in an RN-BSN or RN-MSN program within 1 year of hire and completion within 5 years of hire if hired after July 1, 2012

    • Licensure/Certification

      • Required: California Registered Nurse

      • Preferred: Certification in Case Management

    • Experience

      • Required: Three years as RN in acute setting

      • Preferred: Case Management/UM experience

  • Essential Responsibilities

    • Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.

    • Coordinate all activities related to the appeal process working in conjunction with the interdisciplinary team for their consensus.

    • Work with Business Office to clarify questions related to the denial.

    • Work with Denial Manager and/or CM Directors to secure approval to proceed with appeals.

    • Work with Patient Business services to coordinate tracking and billing of appeal activity.

    • Evaluate records for compliance with regulatory standards.

    • Applies approved clinical appropriateness criteria to evaluate appropriateness of admissions and continued stays, and documents findings based on Department standards.

    • Ensures that all elements critical to support patient status are documented clearly in the medical record.

    • Collaborates with Case Management leadership to make determinations and recommendations for appeals and billing levels of care.

    • Refers cases and issues to hospital leadership in compliance with Department protocols and follows up as indicated.

    • Collaborates with Patient Business Services to facilitate accurate billing and claims payment.

    • Works collaboratively and maintains active communication with other internal RAC team members to timely and appropriate decision making.

    • Maintains knowledge of current regulatory and compliance requirements.

    • Identifies addresses and works to resolve system problems impacting compliance.

    • Escalates issues as appropriate, as defined by Department protocols.

    • Assist in the preparation of summary reports and audit results.

    • Collects, analyzes and addresses data to drive practice change and positively impact outcomes.

    • Adheres to all Eisenhower Health policies, procedures and standards, within budgetary specifications, including time management, productivity and accuracy of practice.

    • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff.

    • Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.

    • Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.

    • Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

    • Other duties as assigned.

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