Appeals and Grievance Registered Nurse II - TLRA Clinical Appeals

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.

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Responsibilities

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• Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services
• Review governmental contractors response letter in comparison to the medical records
• Communicates with facility regarding missing or insufficient medical documentation
• Review medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided
• Research issues using federal or law, federal regulations, and relevant CMS policies Communicates with members of the healthcare team identifying root causes for potential denials
• Communicates with the CMO/VPMA regarding appeals and obtain signature for appeals
• Assures all discussions and appeals are filed timely
• Completes data entry in the Denial database for tracking, trends, and analysis