Experience with InterQual and/or MCG criteria certification/training
Also asks
Medical Necessity Appeal Functions
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Also asks
Review medical necessity denials and evaluate the medical record against payer policy, InterQual/MCG criteria, and CMS guidelines to determine if an appeal is warranted
Also asks
Author clear, well-supported medical necessity appeal letters based on clinical documentation, payer policy, and medical necessity criteria
Also asks
Escalate complex or clinically ambiguous cases to a Physician Advisor for review and guidance
Also asks
Collaborate with Physician Advisors on cases requiring physician-level clinical judgment or peer-to-peer support
Also asks
Manage assigned denial review work queues to ensure timely turnaround within client or payer deadlines
Also asks
Regulatory research as needed to support CMS requirements for medical necessity
The UR Nurse Appeal Specialist is responsible for reviewing payer denials and authoring appeal letters, with a primary focus on Medical Necessity denials. Using strong utilization review experience and clinical judgment, the UR Nurse Appeal Specialist evaluates the medical record against payer policy, InterQual/MCG criteria, and CMS guidelines to determine whether a denial is supported by the documentation or should be appealed. The UR Nurse Appeal Specialist works under the oversight of a Physician Advisor and collaborates closely with the broader Appeal Service Line to ensure appeals are accurate, well-supported, and submitted within payer deadlines.
Requirements
Medical Necessity Appeal Functions
Review medical necessity denials and evaluate the medical record against payer policy, InterQual/MCG criteria, and CMS guidelines to determine if an appeal is warranted
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Author clear, well-supported medical necessity appeal letters based on clinical documentation, payer policy, and medical necessity criteria
Escalate complex or clinically ambiguous cases to a Physician Advisor for review and guidance
Collaborate with Physician Advisors on cases requiring physician-level clinical judgment or peer-to-peer support
Manage assigned denial review work queues to ensure timely turnaround within client or payer deadlines
Regulatory research as needed to support CMS requirements for medical necessity
Denials Management Functions
Track and trend denial reasons and outcomes to identify patterns and opportunities for improvement
Maintain accurate and organized documentation of all denial reviews and appeal outcomes
Communicate with case management, utilization management, and clinical documentation staff as needed to gather supporting information
Provide input and recommendations to Brundage Group leadership for process improvement and template refinement
Client & Operational Support
Work collaboratively with operations, client engagement, and clinical account executives to ensure cases are received and processed in a timely manner to meet payer deadlines
Maintain IT access to client sites
Maintains HIPAA compliance
Other duties as assigned.
Strong utilization review/utilization management experience, including working knowledge of InterQual and/or MCG criteria
Strong critical thinking skills and meticulous attention to detail
Demonstrated ability to author clear, well-organized, and persuasive appeal letters
Strong understanding of medical necessity criteria and payer policy
Excellent written and verbal communication skills
Strong interpersonal skills and ability to build relationships with key team members
Ability to work independently and manage a caseload against payer deadlines
Strong computer skills and working knowledge of EMRs
Work experience, education and certifications
Registered Nurse (RN) with at least 3 years of acute care hospital experience
Minimum of 3 years of utilization review/utilization management experience
Prior experience authoring medical necessity appeal letters required
Experience with acute care hospital settings preferred
Preferred Qualifications
CCM (Certified Case Manager)
ACM (Accredited Case Manager)
CHCQM certification (ABQAURP)
Certified Managed Care Nurse (CMCN)
Case Management Board Certification (CMGT-BC)
Experience with InterQual and/or MCG criteria certification/training
Conditions typically associated with an office environment. While performing the essential duties and responsibilities, the employee is regularly required to talk or hear. May be frequently required to sit, stand or walk. Moderate to prolonged reading, typing, and computer work. Ability to perform tasks involving physical activity that may include lifting up to 25 pounds. Subject to exposure to all environmental hazards associated with healthcare and office work.
