Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility.
o Current RN Nursing license o Interqual and/or MCG certification preferred. Case Management (CCM) or Managed Care certification preferred.
Graduate of an accredited School of Nursing with an Associate or Bachelor's degree (Preferred) in nursing
o Two to four years of Case Management experience. o Two-three years' experience in the denial and appeal process. o Experience with managed care, governmental and/or RAC appeals strongly preferred. o Able to apply InterQual and Milliman Care Guidelines (MCG) medical necessity criteria to a case as applicable. o Understanding of Medicare, Medicaid and third party reimbursement methodologies.
Ability to perform the essential functions of this position, with or without reasonable accommodation and without posing a direct threat to the health and safety of self or others. Ability to comply with all Good Shepherd policies and procedures that are job-related and consistent with business necessity. Ability to effectively communicate with patients and provide competent care as appropriate to the ages of patients served by this position.
o Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task o Intensive writing capabilities/efficiencies. o Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff). o Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomes. o Assertive and diplomatic communication, proven ability to function on a multidisciplinary team. o Excellent organizational skills including effective time management, priority setting and process improvement.
Our Mission: WHY WE EXIST. To extend the healing ministry of Jesus Christ. Our Core Values: WHAT WE BELIEVE IN.DIGNITY Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. INTEGRITY Honesty, justice, and consistency in all relationships. EXCELLENCE High standards of service and performance. COMPASSION Service in a spirit of empathy, love, and concern. STEWARDSHIP Wise and just use of talents and resources in a collaborative manner.Our Vision: WHAT WE ARE STRIVING TO DO. CHRISTUS HEALTH, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God's healing presence and love. Our Name and Symbol:WHO WE ARE. CHRISTUS is Latin for "Christ," and proclaims publicly the core of our mission. OUR NAME choice also recognizes the heritage of our two congregational sponsors, the Sisters of Charity of the Incarnate Word in Houston and San Antonio. Jesus Christ is the Incarnate Word, the Word of God made flesh. It is, theref...ore, only fitting that it is in another form of His name that our health ministries are called together. OUR SYMBOL Reflects the healing ministry of Jesus Christ - a combination of a medical cross and a religious cross. The flowing banner on the cross is a common symbol of the risen Christ, while the royal purple signifies Christ. The flowing banner also conveys a sense of motion as we move forward into a new era of service to our communities.