Registered Nurse Appeals Analyst

Must have home health & hospice experience

The Appeals Analyst performs medical record reviews to determine the quality of care, identifies quality issues, and assures compliance with medical record standards and regulatory mandates as related to billing compliance. The incumbent analyzes submitted claims and/or claims to be submitted as well as medical records to determine benefit coverage for medical services under review. This position educates providers on all aspects of medical record criteria to determine benefit coverage for medical services. This position prepares written documents and/or reports of completed medical review determinations and submits records to the payer, as requested.

Job Requirements

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Education

Must be a graduate from an accredited nursing school. A Bachelor’s Degree in Nursing is preferred. *

Experience

Minimum three (3) years of experience as a registered nurse in a home health and/or hospice clinical care setting is required. Prior functional working experience in medical records review arena (Utilization Review, Case Management and knowledge of appropriate billing and coding guidelines) is required.

• CERTIFICATION/

Licensure

Current License as a Registered Nurse is required. *

Skills

• Interpersonal skills and ability to manage workload and meet deadlines
• Demonstrated professional oral and written communication skills
• Demonstrated strong organizational skills as well as autonomy with tasks assigned
• Demonstrated ability to think critically and adapt to changes
• Excellent analytical, problem solving, and negotiation skills
• Ability to comprehend medical policy and criteria to clearly articulate health information
• Demonstrated ongoing understanding of current Medicare, Medicaid, and third-party regulations as changes occur
• Demonstrated knowledge in all levels of home health, hospice, palliative, and home medical equipment practices
• Demonstrated proficiency in use of Microsoft Office Suite (Excel, Microsoft Word, Power Point, Outlook)
• TRANSPORTATION: Not applicable.
• TRAVEL: Not applicable.
• HEALTH STATUS: Meets all applicable agency policies and procedures related to health screening and required testing.

Key Accountabilities

• Ensures that all activities performed align with the vision of Elara Caring’s board of directors, executive team, and the leadership of the Compliance team.
• Promotes compliance with all regulatory standards, through review of medical records.
• Maintains productivity, quality, and accuracy targets set by the Governmental Review Manager.
• Participates in Administrative Law Judge hearings as the company expert.

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• Educates providers on all aspects of medical review criteria.
• Participates in the appeals process for claims denied by the government or other payers, as necessary.
• Collects appropriate medical records, reviews the documentation for validity, and submits the requested documents for pre-claim reviews, ADR requests, and/or appeals.
• Collaborates with providers to adhere to clinical standards of care to ensure appropriate outcome.
• Practices and adheres to departmental, state, and national guidelines.
• Communicates with agencies related to documentation needs in a timely manner and follows up with agency leadership, as needed.
• Conducts audits, as needed to ensure documentation adequacy.
• Provides education related to audit trends and denials.
• Communicates significant findings, problems, and changes related to compliance with documentation standards to the director and other personnel involved with patient care.
• Identifies and communicates to Governmental Review Manager and other supervisory personnel visit documentation that lacks adequate content to support billing guidelines.
• Participates in the development of strategies/education to prevent loss of revenue during recovery audits.
• Assists with development of staff education tools/guides to promote appropriate clinical documentation and utilization.
• Writes business letters and reports to explain determinations and decisions to a variety of audiences, including, but not limited to governmental payers, private insurance providers, and administrative law judges.
• Participates in all levels of appeal, using regulatory guidance and critical thinking to navigate appeals compliantly.
• Promotes, coordinates, and evaluates operational Systems to enhance operations and promote efficiencies.
• Provides leadership to team and support staff in identifying agency/client needs and opportunities for improvement.
• Promotes Elara Caring’s philosophy, mission statement and administrative policies to ensure quality of care.
• Maintains patient and staff privacy and confidentiality pursuant to HIPAA Privacy Final Rule.
• Performs other duties/projects as assigned.

Physical And Environmental Demands

• Mentally demanding, high stress environment
• Sit, stand, bend, lift and move intermittently and be able to lift at least 25 lbs.
• Move equipment and supplies necessary for job functions
• Read, speak, and write English in order to fulfill job functions in an understandable way
• See/hear or use prosthetics that enable accomplishment of job
• Meet the health requirements of the agency
• Possible exposure to infectious and communicable diseases, chemicals, and repetitive motions
• Abide by all occupational safety and bloodborne pathogen protocol to minimize illness and/or injury
• Complete required work daily
• Cope with work involving ill, disabled, and dying patients

Equal Employment Opportunity: We are proud to be an equal opportunity workplace and comply with state and federal affirmative action requirements. Individuals are recruited, hired, assigned and promoted without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, protected veteran status, or any other protected characteristic. If you require assistance due to a disability in the application or recruitment process, please submit a request via email at recruiting@elara.com.

Pay & Benefit Information: Compensation for this role will be determined based on a variety of factors, including qualifications, skills, competencies, and relevant experience. Elara offers a broad range of benefits. Learn more at https://careers.elara.com/us/en/benefits

EVerify: Elara Caring participates in E-Verify after a job offer is accepted and Form I-9 completed.