Clinical Appeals Nurse (medical necessity)

Full-time | Remote | Permanent Managed Resources is a leading consulting group assisting healthcare organizations nationwide in optimizing its revenue cycle management through review, recovery and educational programs. Please read the below description and apply if you meet the requirements and would like to hear more about this opportunity with Managed Resources! Purpose: Our Clinical Appeals Review services consists of reviewing and appealing for reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not Medically Necessary. Reports to: Assistant Manager of Clinical Appeals Accountabilities: Write quality appeal letters to achieve maximum overturn rate. Ensure workload is completed in an efficient and timely manner.

The Clinical Appeals Review Nurse will review the case, and determine the potential for a Provider Appeal, on the denied claim. The request for reconsideration will be written in an objective narrative form, utilizing appropriate formatting, English grammar, current nationally accepted criteria, medical literature if applicable, healthcare statutes and clinical judgment. Once completed, the letter will be forwarded to the Clinical Appeals Manager for review and approval and then to the payer source for reconsideration. The Clinical Appeals Review nurse will provide the application of current prudent clinical judgment for the case's purpose. The diagnosis, treatment of an illness, injury, and/or disease of its symptoms, will be in accordance with generally accepted standards of medical practice. The clinical review of the denied stay will be evaluated in terms of type, frequency, extent, site and duration of patient’s illness and/or injury or disease. The clinical review of the case will not be based on convenience factors for the patient, facility, physician, and/or other health care professionals. The Clinical Appeal Review Nurse will receive appropriate documentation which includes previous determination information and complete medical record for review. The review will be written in a narrative, professional manner, with an appropriate review of the clinical facts. The letter will include the medically appropriate reasons for the reconsideration of the denial. Once the review is completed, the Clinical Appeal Review Nurse will forward the reconsideration letter to the corporate office, through a secure website, for review by the Clinical Appeals Manager. Once approved, the letter is mailed with attached medical records to the appropriate entity. The Clinical Appeals Review Nurse will then update the applicable logs for appropriate follow up purposes including payor requested reports.