Appeals Reviewer Veteran Job Description Samples

Results for the star of Appeals Reviewer Veteran

Clinical Appeal Nurse Reviewer

What you'll get to do: The Clinical Appeals Nurse Reviewer is responsible for assessing the appropriateness of determinations made on appealed clinical benefit determinations and those that may be determined if case proceeds to external review and/or internal litigation. This includes reassessment of the appropriateness of the initial or appealed determination and the upholding or reversing of previous determinations. Frequently this involves communication with members in the midst of a treatment plan or requiring acute or chronic care. This role is responsible for researching and documenting case history in compliance with policies and procedures related to hearings and regulatory agency inquiries. In addition, it is responsible for the analysis of trends, which may be identified through the review of cases, and for addressing these issues by recommending review of medical and utilization management and/or clinical appeals policies. This person supports the development, planning and implementation of departmental and cross-departmental projects designed to improve operations and promote excellence.

Qualifications: * Bachelor's or Associate's degree in Nursing required; BSN or BS/BA preferred * 3 years clinical experience required; experience working with Medicare products and members and/or experience working in homecare strongly preferred

  • Previous outpatient utilization review experience in a managed care environment preferred Required Certification/Licensure: * Valid, unrestricted MN RN license required Skills and Abilities: * Medical knowledge and background

  • Critical thinking skills

  • Ability to organize and present case in logical, sequential order

  • Attention to detail and accuracy

  • Flexibility in managing changes in job duties and work environment

  • Excellent written and verbal communications skills

  • Innovative problem solving skills

  • Able to focus on a variety of issues at one time

  • Relates well to internal and external customers

  • Demonstrates ability to use Microsoft Office suite

  • Strong customer service skills

  • Ability to think creatively, negotiate and access appropriate resources Equal Opportunity Employer including Veterans and Disabled Individuals * Thrive Together. At Medica, you'll enjoy working with talented people who share a mission to meet our customers' needs.* * Grow Together. Medica will support you through your personal growth and involvement in the community.* * Succeed Together. Medica provides resources that allow you to take charge of your health and career.*

Title:Clinical Appeal Nurse Reviewer


Requisition ID:17122

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Appeals Reviewer RN

Appeals Reviewer RN Department: Case Management Resource Center Schedule:

Per diem Shift: AM shift Hours: Job Details:

Glendale Adventist Medical Center (GAMC) is a 515-bed hospital built on the Seventh-day Adventist faith and mission to improve the health of communities and to share God's love by promoting healing and wellness for the whole person. Job Summary: The Appeals Reviewer RN is responsible for recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review, and the preparation of documentation of appeals based on disputed/denied clinical criteria.

The preparation of this information will be based on accepted industry criteria. Job Duties: Performs retrospective, post discharge, and post serviced medical necessity review to determine appellate potential of clinical disputes/denial or those eligible for clinical review.

Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate medical necessity criteria. If clinical review does not meet InterQual criteria, other pertinent clinical facts are utilized to support the appeal. Demonstrates ability to critically think, problem solve, and make independent decision supporting the clinical appeal process.

Demonstrates proficiency in utilization of electronic tools, including but not limited to Cerner Power Chart, Cerner Care Management, and RCI revenue applications. Must have strong clinical assessment and critical thinking skills necessary to identify potential quality issues, delays in service, post-acute care needs required Requirements: Must possess a current, valid CA nursing license Minimum of 5 years recent acute experience.

Medical-surgical /Critical care experience preferred, but not required. Minimum of 2 years UR/Case Management experience.

Managed care payer experience a plus either in Utilization, Case Management or Appeals.

Benefits (based on hours & position): Medical, dental, vision and prescription coverage, Group life and AD&D insurance, Matching 401(k) and 403(b) retirement plans, Long-term disability insurance, Tuition reimbursement, On-site child care and more! HR Use Only:

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Utilization Review Appeals Specialist

17-3686 Post Date 7/7/2017 Title Utilization Review Appeals Specialist Job Family Nursing Subsidiary McLaren Flint Department 91590 - Utilization Management Location Flint Region City Flint State MI Full Time Yes Hours per 2 week pay period 80 Schedule 8:00 a.m. - 4:30 p.m. w/ 1 hour variable start/end Weekends and/or Holidays Required Yes On Call Required No Description JOB SUMMARY Under the direction of the Utilization Management Manager, coordinates/handles the appeals process for third party payor denials, primarily RAC related activities and commercial appeals beyond the first level, requiring complex clinical review. This position is also for responsible for collecting, analyzing and reporting clinical risk factors for level of care discrepancies. This position will support the overall quality, completeness of clinical documentation and intensity of service application during the appeal process to ensure proper reimbursement is achieved. REQUIRED QUALIFICATIONS + Licensed Registered Nurse (RN) in the State of Michigan

  • BSN or Bachelor degree in health related field or completion within 3 years of accepting the position.

  • Three years of case management or utilization review experience.

  • Experience coordinating or leading projects. PREFERRED QUALIFICATIONS + Knowledge of care delivery systems across the continuum of care including, but not limited to, trends and issues in care reimbursement, scope of alternate site care, and available community resources.

  • 3 - 5 years recent experience doing third party payor certification.

  • 1 year of appeal experience with third party payors.

  • Proficiency with database, spreadsheets and word processing programs.

  • Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities. Apply On-line Send This Job to a Friend © All rights reserved

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Registered Nurse Clinical Denials And Appeals Reviewer - Finance (Ch)

Job Description

  • Registered Nurse Clinical Denials and Appeals Reviewer Finance (Catholic Health):
    This position is accountable for carrying out and documenting the appeals process for denied claims denied due to reasons including, but not limited to clinical documentation/support for DRG assignment, inpatient and outpatient medical necessity. The individual also works to maintain third-party payer relationships. This includes, but is not limited to, responding to inquiries, complaints, and other correspondence, and may include setting up arbitration between parties. Knowledge of state and federal laws relating to contracts and appeal processes is vital. Additional responsibilities include identification of root cause and process improvement opportunities to eliminate recurring clinical denials. The position acts as a liaison between front-end clinical areas and third party payers in scenarios related to denials and appeals.
    Manager, Revenue Cycle Improvement
    Registered Nurse with a current New York State license
    Bachelor of Science Nursing degree
    Holds, or will obtain within one year of hire, one of the following (or similar) credentials: Certified Documentation Specialist, Certified Coder (CPC/CCS), Certified Processional Medical Auditor (CPMA), Certified Case Manager (CCM) or any other certification approved by management
    Three (3) years of active nursing experience in acute care setting, coding, and/or case management strongly preferred
    Three (3 ) years of experience at monitoring, reviewing and appealing clinical denials or relevant experience preferred
    Experience in working with third party payers strongly preferred
    Knowledge, Skill and Ability
    Excellent interpersonal skills working with the medical, nursing, case management, patient accounts, finance, managed care services and third party payors
    Strong verbal and written communication and presentation skills
    Demonstrates organizational skill, problem solving skills, facilitation, critical thinking and decision making
    Extensive knowledge of third party payer guidelines (InterQual), accreditation and regulatory requirements
    Knowledge of Manage Care Organization contracts/agreements
    PC literate, spreadsheet work, analytical skills for reporting and interpretation

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Senior Recovery Resolution Analyst - C&S Appeal Clinical Reviewer - US Telecommute

Position Description:
Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.SM
The Senior Recovery / Resolution Analyst will work with a team on researching issues to determine feasibility of reducing medical costs through prospective solutions of claim system processes and claim business rules.
Positions in this function are responsible for investigating, recovering and resolving all types of claims as well as recovery and resolution for health plans, commercial customers and government entities. May include initiating telephone calls to members, providers and other insurance companies to gather coordination of benefits data. Investigate and pursue recoveries and payables on subrogation claims and file management. Process recovery on claims. Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance. May conduct contestable investigations to review medical history. May monitor large claims including transplant cases

  • Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
  • Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
  • Investigate and pursue recoveries and payables on subrogation claims and file management
  • Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits information
  • Process recovery on claims
  • Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
  • Use pertinent data and facts to identify and solve a range of problems within area of expertise
  • Generally, work is self - directed and not prescribed
  • Works with less structured, more complex issues
  • Serves as a resource to others

  • High School Diploma / GED
  • Ability to work Monday - Friday 8:00 AM - 4:30 PM, CST with the flexibility to work evenings and / or weekends as business needs arise
  • Certified Coder (CPC or CCS) and / or current LPN / RN Licensure
  • 3+ years of experience auditing claims or medical coding
  • 1+ years of experience in understanding and applying Centers for Medicare and Medicaid Policies and Regulations
  • Experience working with computers and PC applications and ability to learn new applications.
Soft Skills:
  • Ability to work on the computer while on the phone
Physical Requirements and Work Environment:
  • Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health - related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group
is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Keywords: UHG, Optum
, Claims, Community & State, C&S, auditing, clinical, appeals, telecommute

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Appeals And Medical Review RN


The Appeals and Medical Review Nurse works closely with the clinical, financial departments and physicians to minimize the impact of denials through preparing and overseeing the appeals efforts in the organization. This requires a strong clinical background, diligence in research and attention to details.

Review records for any accounts that have been denied for medical necessity and provide feedback as to the appropriateness of the status of the account.

  • Evaluation of denials received occur within 5 working days of receipt
  • Records are reviewed to determine if appeal is feasible based on medical necessity
  • Questionable cases are reviewed with Director
  • Records are prepared for appeal submission

Work closely with the utilization review staff, physicians and Executive Health Resources staff to complete the appeals process.

  • Effective relationship with Utilization Review staff
  • Upload cases to EHR portal to ensure timely processing of appeals
  • Download communications from EHR on a daily basis and update accounts with any new information received
  • Close accounts that have been overturned or all levels of appeal have been exhausted

Review processes involved in clinical documentation into the electronic record for opportunities for improvement and prevention of denials.

  • Work closely with the physicians to ensure compliance with documentation requirements
  • Contact physician offices to obtain additional information if needed
  • Develop standard documentation templates for physicians to ensure all required elements of documentation are captured

Demonstrates knowledge of utilization review practices, including application of Interqual criteria, standards of medical care, local and national coverage determinations and contract terms.

Utilize Interqual criteria to ensure correct statusing of accounts and appropriate continued stay

  • Review NCD and LCD on regular bases to ensure that up to date requirements for medical necessity documentation are communicated to physicians
  • Familiar with contract terms for major payers
  • Identify and report trends in initial and concurrent review process contributing to denials

Consistent favorable guest relations and customer service.

  • Positive team spirit through optimistic comments about the care management, the profession of nursing, and Good Shepherd Medical Center.
  • Excellent public relations externally and internally.
  • Satisfaction with service as evidenced by favorable survey results, personal visits, etc.
  • All complaints are responded to in an appropriate and timely manner.
  • Maintenance of patient rights and function as patient advocate
  • Adherence to the GSMC professional dress code policy

Compliance with applicable laws, regulations, and accreditation standards.

  • Knowledge of regulatory and payer requirements
  • Improvement in patient care demonstrated through quality assessment and improvement program.
  • Evidence of safe work practices.
  • Accident-free work environment.
  • Demonstration of concern for the esthetics of the hospital

Incorporates, evaluates, promotes, and participates in research into the practice setting

Demonstration and assurance of competence as appropriate to the ages of the patients

Ability to meet the needs of the patient, family and others.

Knowledge of growth and development and its relationship to treatment.

Consistently combines an awareness of patients' rights and ethical judgement for following through with appropriate action to function as a patient advocate.

  • Knowledge of Code of Ethics policy and procedure
  • Identifies and reports ethical issues following appropriate chain of command


RN Required, BSN preferred

Associated topics: cardiothoracic, care unit, infusion, maternal, mhb, psychatric, recovery, registered nurse, surgery, unit

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Annual Appeals Coordinator (Temp2)


  • Provide support to the Donor Relations Assistant were needed.

  • Provide Administrative support to the Annual Appeals department by processing inventory orders and seeing that needed office supplies are ordered.

  • Assist the Database Specialist with the processing of credit card donations and entering credit card batches into the database as instructed.

  • Assist the Database Specialist with cleaning donor accounts from changes that come in from our Lock Box Company during the Christmas season.

  • Assist in the printing of Checks off of the WIA cue.

  • Assist with the research of donor problems, complaints, inquiries and requests as needed by the Donor Relations Specialist.

  • Work with Database and Annual Appeals Manager as well as the Donor Relations Assistant on merging duplicate account records on database.

  • Assist with the research of donor problems, complaints, inquiries and requests as needed by the Donor Relations Specialist.

  • Perform clerical activities such as photocopying, faxing, mailing, emailing answering phones and filing as well as ordering office supplies.

  • Assist the Donor Relations Specialist with other activities when necessary.

  • Work extra hoursonlywhen requested by the Database and Annual Appeals Manager.

  • Perform various additional duties integral to the effective operation of the Annual Appeals department and fundraising sections of the Development Department as needed. Qualifications: + Computer Proficiency – (Word and Excel) + Data Entry Experience + Ability to manage multiple tasks + Attention to Detail + Filing All qualified applicants will receive consideration for employment without regard to race, color, sex, national origin, disability or protected veteran status Job ID 2016-2510 Job Locations US-NY-New York Category Administrative Compensation Salary is $20.00/HR Compensation Min Compensation Max Type Regular Full-Time

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Appeals Specialist

McKesson is in the business of better health and we touch the lives of patients in virtually every aspect of healthcare. At McKesson Specialty Health, our products and services span the full continuum of specialty patient care.

From the initial phases of a product life cycle and the distribution of specialty drugs, to fully integrated healthcare technology systems, practice management support, and ultimately to patient care in the communities where they live, we empower the community patient care delivery system by helping community practices advance the science, technology and quality of care. We have a vision —that the long-term vibrancy of community care will be achieved through the leadership of physicians committed to clinical excellence and innovation, enabled by close collaboration with our organization and our deep clinical, operational and technological expertise.Every single McKesson employee contributes to our mission—by joining McKesson Specialty Health you act as a catalyst in a chain of events that helps millions of people all over the globe. You’ll collaborate on the products and solutions that help us carry out our mission to improve lives and advance healthcare.

Working here is your opportunity to shape an industry that’s vital to us all. Join our team of leaders to begin a rewarding career.

Position Description + Responsible for the enteringnew appeal cases and monitoring cases until appeal process is completed.

  • Completes preliminary investigation of the denied claims,checking for coding accuracy and gathering medicalrecords and supporting evidence from drug compendia.

  • Works on denials moderately complex in nature where judgmentis required to understand what medical recordsare required to support the necessity of treatment.

  • Normally receiveslittle or no instruction on routine work, general instruction and guidance on new or more complexcases.

Key Responsibilities + Organizes incomingappeal cases and maintains timelyfollow-up actions for the case + Preliminary investigation to determine the reason for the denial through researchof the FDA drug label,Compendia, and medicallibrary resources.

  • Gathers necessary medical records to support the appeal on denied dates of service.

  • Audit denied claim(s)for accuracy of coding. Requiresknowledge of ICD-10 CPT and HCPCS code sets.

  • Ability to developand write an appeal argumentwith the supportof the Clinical AppealsSpecialist.

  • Maintains knowledgeof pharmaceutical patientassistance programs to seek appropriate support on lost cases.

Minimum Requirements 3 years of medical billing experience with account follow-up and/or appeals

Critical Skills + Knowledge of medical terminology + Knowledge of medical billingprocesses + Knowledge of medical coding (ICD-10, CPT and HCPCS code sets) + Knowledge of Microsoft Word and Excel + Strong writtenand oral communication skills + Critical thinking skills Additional Knowledge & Skills

Additional medical billing or coding education preferred Education High School Diploma or equivalent work experience; CCP or AAPC preferred.

Physical Requirements

General Office Demands Benefits & Company Statement McKesson believes superior performance – individual and team – that helps us drive innovations and solutions to promote better health should be recognized and rewarded. We provide a competitive compensation program to attract, retain and motivate a high-performance workforce, and it’s flexible enough to meet the different needs of our diverse employee population.

We are in the business of better health and we touch the lives of patients in virtually every aspect of healthcare.

We partner with payers, hospitals, physician offices, pharmacies, pharmaceutical companies and others across the spectrum of care to build healthier organizations that deliver better care to patients in every setting. But we can’t do it without you.

Every single McKesson employee contributes to our mission—whatever your title, whatever your role, you act as a catalyst in a chain of events that helps millions of people all over the globe. Talented, compassionate people are the future of our company—and of healthcare. At McKesson, you’ll collaborate on the products and solutions that help us carry out our mission to improve lives and advance healthcare.

Working here is your opportunity to shape an industry that’s vital to us all. McKesson is an equal opportunity and affirmative action employer – minorities/females/veterans/persons with disabilities. Qualified applicants will not be disqualified from consideration for employment based upon criminal history.

Agency Statement No agencies please.


Organization:McKesson Specialty Health

Title:Appeals Specialist

Location:Kansas-Overland Park

Requisition ID:17003983

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Appeals Nurse

Children's Hospital of New Orleans is a leader in Pediatric care throughout the Southeast region. We are currently seeking an Appeals Nurse.

The Case Management Appeal Nurse is responsible for management of all hospital inpatient and observation status type - post discharge denials and appeals for CHNOLA from receipt to resolution. This position will be a liaison and point of contact between CHNOLA Case Management and all third party payors for medical necessity, no authorization and status denial and appeal inquiries and communication. Based on InterQual, MCG or other relevant community and CHNOLA guidelines, the Case Management Appeal Nurse will review each denied case related to medical necessity and/or no authorization, both concurrent and retrospective, and implement the appeal process ensuring the payor’s time-frame requirements for submitting an appeal are met.

Other key responsibilities will include interfacing, collaborating and partnering with all Revenue Cycle departments and staff in supporting an efficient denial management program that positively impacts the revenue cycle. Additionally, this position will oversee the data entry and maintenance of the denial and appeal-tracking log with generation of a monthly denial summary report of all activities. The ideal candidate will have 5-7 years of clinical experience and at least 3 years experience in Utilization Review, Case Management or Revenue Cycle, in a hospital or HMO environment.

Preferred: + Knowledge of the reimbursement methodologies of Managed Care contractual agreements, DRG and APC structure and regulatory requirements + Previous experience managing denials and appeals in a hospital setting + Knowledge of state, federal and third party payor rules and regulations regarding hospital services The mission of making care available to all children has allowed Children's to grow as an organization. Children's Hospital is a 247-bed, not-for-profit medical center offering the most advanced pediatric care for children from birth to 21 years. With over 40 pediatric specialties and more than 400 physicians, it is the only full-service hospital exclusively for children in Louisiana and the Gulf South.

We invite you to experience the magic of Children's Hospital. As a member of our team, you will not only experience personal reward, you will also find tangible benefits for you and your family. For more information please go to

Children's Hospital is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, age, status as a protected veteran, or status as a qualified individual with di verse background.

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Clinical Appeals Analyst

Job Description: Responsible for the analysis, research and completion of complex, non-routine appeals and grievances within the company. Will address all customer concerns and ensure resolution and satisfaction. Ensure timeliness, quality and efficiency in all work to comply with mandated, legislative, North Carolina Department of Insurance (NCDOI) and National Committee for Quality Assurance (NCQA) and Federal requirements. Note: This job reports to Manager, Nursing or Team Leader, Medical only.

  • Provide clinical consultation with non-clinical staff within the Appeals Department.

  • Coordinate all aspects of the appeals process to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI, legislative, federal and NCQA requirements, as applicable.

  • Assist with Level 3 appeals as required.

  • Analyze complex/non-routine member and provider appeals and grievances for all lines of business, excluding FEP, by reviewing CMP, contract provisions, legislation and/or NCQA requirements.

  • Identify appropriate documentation collection from multiple external sources such as pharmaceutical companies, attorneys, providers, etc.

  • Present analysis and documentation to appropriate physician committee, benefit administrators and BCBSNC leadership, as necessary.

  • Initiate claim adjustments on individual cases when necessary.

  • Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by mandates and legislation.

  • Identify trends and high-risk issues to make recommendations to address future exposure.

  • Identify and take corrective action on appeals that result from noncompliance of contract provisions, appeal guidelines and/or CMP.

  • Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors.

  • Answer member/provider questions via incoming telephone calls in a professional quality driven manner.

  • May handle complaints/grievances as defined by the federal government.

  • Coordinates with external vendors and provides requested information as requested. Hiring Requirements + Registered Nurse in the state of North Carolina + 3 years of clinical experence; OR + Licensed Practical Nurse, Physical Therapist, Occupational Therapist, Licensed in the State of North Carolina and 5 years of clinical experience. Hiring Preferences + Managed care experience

  • Experience with Blue Cross and Blue Shield of North Carolina products and systems.

  • System knowledge should include understanding and usability of MaxMC, Power MHS, Service First, Magic, Mobius, Doc Request, Medco and accessing Corporate Medical Policy.

  • Experience with of MS Word, Access, and Excel.

  • Ability to research and problem solve + Able to read and understand claims history, denials, payments, suspends + Strong Medical Knowledge

  • Ability to make concise, independent and defensible decisions in often high-pressure situations + Effective verbal and written communication and presentation skills + Excellent analytical, planning and problem-solving skills

  • Ability to successfully interface with individuals at all levels, including top management, both internal and external + Excellent time management skills

  • Ability to be discreet and diplomatic

  • Ability to work independently, as well as with a team + Certified Professional Coder preferred. It's an exciting time to work at Blue Cross and Blue Shield of North Carolina. Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Our company is a not-for-profit with headquarters in Durham and major operations in Winston-Salem and Fayetteville. In all we employ more than 4,500 North Carolinians and serve more than 3.7 million customers. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

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