Appeals RN - Hospital

Location: Baltimore, MD
Date Posted: 08-31-2018
Denials & Appeals RN – Hospital System
Baltimore, MD
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 6 months, or longer! ***

Your Job Summary:
The Denials & Appeals Nurse performs specific aspects of the Utilization and Quality Management Programs, including denials, appeals, and grievances, and related activities, objectives, and analysis. The nurse supports the organization by working to resolve payment disputes through advanced and complicated case review of the appropriateness of medical care requiring considerable clinical judgment, independent analysis, and detailed knowledge of managed care and organizational guidelines.  The nurse is responsible for oversight and execution of the grievance and appeals process, which includes coordinating the investigation among departments, analysis of root causes, collaborating with staff to develop corrective action plans, and monitoring corrective action taken. Manages the consolidation of the denials, complaints, and grievance activities on a quarterly basis, and prepares monthly, quarterly and annual reports on assigned quality improvement activities.
Your Reward: 
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health. 
Your Background:
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
Bachelor’s of Science in Nursing (B.S.N.) is preferred.
Certified Professional in Healthcare Quality (CPHQ) or similar certification is a plus.
Roughly 2-5 years acute care clinical nursing experience is required.
At least 2-3 years previous experience in Denials & Grievances & Appeals and Utilization Review in a hospital setting.
Direct experience with hospital inpatient/outpatient coding and/or Clinical Documentation Improvement (CDI) practices is preferred.
Direct experience with guidelines for Medicaid/Medicare and related state programs is required.
Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Excellent verbal (customer service) and written (business letter writing) communication skills, as well as exceptional critical thinking skills.
Your Duties:
Facilitates continuous quality improvement in the health system network by providing individualized case review and processing.  Performs clinical review related to Denials, Grievances, Appeals, Quality Audits, and Occurrences by identifying the issues of the case, ordering and collecting needed documents or records, reviewing the case documents, completing a case summary, and either leveling or reviewing the case with senior leadership as appropriate.  Coordinates and submits results of focused review studies, medical record audits as appropriate. 
Acts in the capacity of patient advocate addressing concerns, maintaining absolute file integrity with regards to content, location, and confidentiality.  Conducts clinical review and evaluation of patient and payer denials, complaints, grievances and appeals using considerable clinical judgment, evidence based standards, independent analysis, knowledge of operational policies, clinical guidelines, plan benefit structures and regulatory requirements to determine the appropriateness of care provided.  Reviews, triages and prioritizes cases to meet required turnaround times.  Ensures that appeals and grievances are categorized and processed within appropriate state and federal time frames. Interacts with external partners, including health plans, medical groups, IPAs and other external vendors to obtain additional information to resolve the patient’s case.   Interaction includes preparing for and participating in regulatory site visits.  Performs research and analyzes complex issues.  Identifies potential quality issues and initiates investigations, processing any substantiated quality of care issues.  Summarizes cases including articulation of patient’s perception, initial denial determination and notification, analysis of medical records, and appropriate application of all applicable policies, guidelines, benefit plans and laws, rules and regulations. 
Maintains strict compliance with federal, state and NCQA requirements and guidelines.  Participates in and coordinates Quality Management committee activities by assisting with development of the agenda, providing the assigned meeting documents, and presenting reports.  Provides complete and accurate documentation of work performed by entering data into specified databases or forms as instructed and reporting any required metrics.  Participates in the Quality Management process by identifying problems, examining solutions options, implementing action plans and by coordinating, facilitating and/or participating in inter and intra- departmental quality initiatives and work groups.
443.552.7423 (CALL – TEXT – FAX)
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