Appeals Reviewer Veteran Job Description Samples

Results for the star of Appeals Reviewer Veteran

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. HR Use Only:

Use this job description

Utilization Review Appeals Specialist

17-2132 Post Date 4/19/2017 Title Utilization Review Appeals Specialist Job Family Health Professional Subsidiary McLaren Macomb Department 91570 - Case Management Location Mt. Clemens Region City Mount Clemens State MI Full Time Yes Hours per 2 week pay period 80 Schedule 8:00 a.m. - 4:40 p.m. Weekends and/or Holidays Required No On Call Required No Description JOB SUMMARY Under the direction of the Director, Case Management, 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 + 3 - 5 years recent experience in third party payor certification.

  • 1 year of appeal experience with third party payors.

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

Use this job description

Appeal Nurse Reviewer

Appeal Nurse Reviewer Responsibilities

  • Investigate and resolve medical necessity appeals and maintain documentation
  • Collaborate with internal and external medical colleagues and Medical Directors in order to maintain a timely process
  • Respond to member, provider and other customer telephone inquiries regarding status, process and outcomes of appeals
  • Identify potential quality of care issues within medical appeals: escalate as appropriate
  • Participate in departmental audits and regulatory site visits
  • Perform trend analysis and make recommendations for process improvements
  • Resource to non-clinical members of the department

Appeal Nurse Reviewer Requirements

  • Active, unrestricted Illinois Nursing / Registered Nurse licensee
  • Bachelor's degree in nursing at a minimum
  • Working knowledge of national practice guidelines and or UM medical necessity guidelines such as Milliman, InterQual and or Apollo
  • 3-5 years clinical experience
  • Previous experience handling appeals for the Medicaid and Medicare population
  • Experience in a managed care environment
  • Familiarity with NCQA standards
  • High level of organizational skills and able to manage multiple priorities
  • Effective verbal and written skills
  • Ability to effectively prioritize and execute tasks in a fast paced environment

Use this job description

Utilization Review & Appeals RN

For more than 100 years, Southern New Hampshire Medical Center has honored our mission: to improve, maintain, and preserve the overall health and well-being of individuals living in the greater Nashua area by providing information, education, and access to exceptional health and medical care services.

We have literally been at the heart of better health for Greater Nashua. Our main downtown campus, a familiar landmark for generations, has grown along with the Gate City. Today, The Medical Center and our affiliated doctors and services extend across much of southern New Hampshire.

Summary:

The Utilization Review & Appeals RN evaluates medical acuity to assess for appropriate level of care orders and documentation to facilitate insurance coverage. Works directly with care team to proactively prevent denials and ensure level of care charges are applied accurately per commercial and CMS insurance guidelines. Appeals medical necessity insurance denials. Conducts charge reviews to ensure insurance rules are followed.

Qualifications:

  • Bachelor's degree in nursing

  • Three to five years experience in acute care Utilization Review and Appeal writing

  • Experience in use of Interqual, Milliman and other Healthcare acute criteria

  • Excellent writen and verbal communication skills

  • Competent in Microsoft Office and general computer skills

Click Here to Apply Online

Current Employees Click Here to Apply Online

External Application Confirm

Are you sure you want to continue as a EXTERNAL applicant?

Yes

No

Internal Application Confirm

Are you sure you want to continue as a INTERNAL applicant?

Yes

No


Use this job description

Senior Appeals Clinical Reviewer (Temp)

ConnectiCare is a leading health plan in the state of Connecticut. ConnectiCare's mission is to make it easy for members to get the care they need. A local company for over 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. A subsidiary of EmblemHealth, ConnectiCare leads the individual and small group markets in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance.
We're looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.

Purpose: Under the direction of the Director, Appeals and Compliance, oversee the daily activities of the Medicare Appeals Coordinators and the Appeals Clinical Reviewer, ensuring adherence to department performance and productivity standards, operational efficiency, and compliance with government regulations and accreditation requirements. Review clinical appeals to facilitate the accurate administration of benefits and maximize appropriate utilization related to medical necessity. *This is a temporary role with a 3 month term.

Key Accountabilities:

  1. Manage the day-to-day operations of the Medicare appeals team. Ensure the appropriate staff responds to all member/provider inquiries accurately and within the stipulated time frames, thereby ensuring member/provider satisfaction, and compliance with regulatory and accreditation requirements.
  2. Carry partial clinical appeals caseload, utilizing the appropriate clinical criteria, CMS and state guidelines, and medical and administrative policies to evaluate medical necessity.
  3. Schedules/triages work, evaluating staff caseloads, and redistributing cases as necessary.
  4. Review daily/weekly reports to monitor appeals inventory and ensure timeframes are met.
  5. Evaluate individual staff performance on an ongoing basis, and develop individual performance improvement and/or professional improvement plans with staff.
  6. Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members. Monitor performance and address any problems during the probationary period.
  7. Oversee employee development and training on all products.
  8. Participate in planning and leading team meetings to foster communication and collaboration within the team.
  9. Create and implement policies and procedures to ensure department goals are met using the most efficient and cost effective measures.
  10. Participate in creating and implementing continuous process and quality improvement initiatives. Conduct root cause analyses and implement process improvements based on findings. Track and trend outcomes, analyze data, report on these to the Director, and recommend modifications to medical necessity criteria, etc., based on trends found for appeals upheld or reversed. When modifications are made, track to measure impact on appeals decisions.
  11. Prepare for and acts as business area liaison for internal and external audits.
  12. Act as a liaison between the Appeals department and other departments. This includes dissemination of accurate, up-to-date information to staff, representing the department in committees and work groups, and facilitating resolution of interdepartmental issues.
  13. Interface with various external customers, including but not limited to, delegates, and accreditation, federal, and state agencies. This involves explaining ConnectiCare's policies and processes as they relate to the external entity, negotiating the resolution of issues, developing workflows, and implementing quality improvements.
  14. Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members. Monitor their performance and address any problems during the probationary period.
  15. Perform other related projects and duties as assigned.

Required Skills:

Technical Knowledge and Experience:

  1. CT R.N. License. Bachelor's Degree in nursing or an equivalent combination of education and experience.
  2. At least 5 years of clinical experience.
  3. At least 3 years in a managed care health care environment, including 2 years' experience in Medicare managed care. Familiarity with applicable state regulations and NCQA standards required.
  4. Supervisory skills sufficient to direct, motivate, and discipline staff are essential.
  5. Must possess initiative, balanced judgment, objectivity and the ability to plan and prioritize one's own work to assure maximum efficiency.
  6. Analytical and technical ability is required to review and analyze appeals outcomes, procedures and workflow and to make recommendations for streamlining the grievance and appeals process within the functional units of the department.
  7. Demonstrated ability to synthesize and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner.
  8. Excellent organization and interpersonal skills are required to interact effectively with all levels of staff.
  9. Must have the ability to prioritize a heavy workload in a dynamic, fast paced environment.
  10. The incumbent must exercise sound decision making in line with the responsibilities of the position and seek assistance when necessary. This includes the ability to set priorities and complete assignments in a timely fashion.

ConnectiCare is an equal opportunity employer. M/F/D/V


Use this job description

Utilization Review Appeals Specialist

Subsidiary: McLaren Flint -

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-lineSend This Job to a Friend

? All rights reserved


Use this job description

Appeals Registered Nurse Reviewer

Job Summary

The RN Appeals Reviewer maintains database of disputed/denied clinical claims and tracking for timely submission of those eligible for appeal either by clinical review, administrative action and settlement. The appeals RN will be responsible for preparation of case review and 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 appeal potential of clinical disputes/denial or those eligible for clinical review.
  • Critical thinking and demonstrates ability to make independent decision supporting the clinical appeal process.
  • Constructs and documents a clear 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.
  • Must have strong clinical assessment and critical thinking skills necessary to identify potential quality issues, delays in service, post-acute care needs required
  • Demonstrates proficiency in utilization of electronic tools, including but not limited to Medetech, Epic,or Care Advance applications.

Requirements

  • Unrestricted valid CA Registered Nurse license
  • Minimum of 2 years UR/Case Management experience.
  • Managed care payer experience a plus either in Utilization, Case Management or Appeals.
  • Minimum of 5 years recent acute experience.
  • Medical-surgical /Critical care experience preferred, but not required.
Job Posted by ApplicantPro

Use this job description

Appeals Reviewer RN - Case Management Resource Center

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.

Use this job description

Clinical Care Review -Provider Appeals

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Note to Applicants: This position will support our Operations UM--Provider Appeals team.

Responsibilities:

Under the direction of the Supervisor, UM-Provider Appeals, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nurse's discretion to pend requests for additional information and/or request clarification. The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit's business and uses clinical judgment in their application.

Education/Experience:

  • Licensed Registered Nurse graduated from an accredited program (ASN, BSN) preferred.

  • Current unrestricted Florida Registered Nurse license.

  • Three or more years' experience in a related clinical setting.

  • Managed care or utilization review experience preferred.

  • Excellent verbal and written communication skills.

  • Ability to identify problems and recommend solutions.

  • Self-directed and the ability to work independently.

  • Ability to advocate for member/member family needs.

Use this job description

Registered Nurse - Appeals

We’re working on behalf of a NYSE-listed company in Tampa that focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage, and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs.  The company serves approximately 3.8 million members nationwide through its quality and cost-effective health care solutions, and is committed to continually improving the quality of care and service its provide to its members, helping them access the right care at the right time in the appropriate setting.
We seek candidates with inpatient experience within an acute care clinical setting (Med Surge, Telemetry, ER or ICU) for the role of Appeals Reviewer.  In this role you will be responsible for preparing cases for physician review and all appeal related activities accurately, efficiently, and within mandated timeline requirements.  You will perform appeal reviews on medical and/or behavioral health records and cases utilizing established guidelines and member benefit plans.  You will communicate the outcome of the appeals process with members, internal and external partners.  You will utilize company designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with appeal determinations.  You will collect information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process.  
Candidates must be a graduate of an accredited school of nursing and be licensed as an RN or LPN in the state of Florida.  Must have two (2) or more years of experience in an acute care clinical setting with general nursing exposure in UM to include pre-auth.   Must have two (2) or more years in Managed Care experience.  Must have working knowledge of InterQual criteria.
Competitive compensation and benefits.   This is an excellent opportunity to join an organization employs more than 7000 employees across the country, and fosters a rewarding and enriching culture that inspires its associates to do well for others and themselves.  For more information call 941.739.1400 or submit your resume now by clicking on the button below that says “Apply Now.”

Use this job description