Clinical Appeals Nurse

JOB SUMMARY

The Revenue Cycle Clinician for the Appellate Solution is responsible for:

• Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review 
• Preparing and documenting appeal based on industry accepted criteria.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

1. Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. 

2. Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization. 

3. Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process. 

4. Adhers to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines. 

5. Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office. 

6.Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc. 

7. Additional responsibilities:

a) Serves as a resource to non-clinical personnel.

b) Provides CRC leadership with sound solutions related to process improvement

c) Assist in development of policy and procedures as business needs dictate.

d) Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Demonstrates proficiency in the application of medical necessity criteria, currently InterQual®
• Possesses excellent written, verbal and professional letter writing skills
• Critical thinker, able to make decisions regarding medical necessity independently
• Ability to interact intelligently and professionally with other clinical and non-clinical partners
• Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms
• Ability to multi-task
• Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
• Ability to conduct research regarding off-label use of medications

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment.  This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience required to perform the job.

• Must possess a valid nursing license (Registered)
• Minimum of 3 yearsacute care experience in a facility environment
• Medical-surgical/critical care experience preferred
• Appeals writing experience preffered
• Minimum of 2 years UR/Case Management experience preferred
• Managed care payor experience a plus either in Utilization Review, Case Management or Appeals
•  
• Previous classroom led instruction on InterQual® or MCG products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred

CERTIFICATES, LICENSES, REGISTRATIONS

• Current, valid RN/ licensure
• Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred

PHYSICAL DEMANDS 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to lift 15-20lbs 
• Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites
• Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews

WORK ENVIRONMENT 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.

OTHER

• May require travel – approximately 10%
• Interaction with facility Case Management, Physician Advisor is a requirement. 

 Compensation and Benefit Information

Compensation

• Pay: $30.85 - $46.28 per hour. Compensation depends on location, qualifications, and experience. 
• Position may be eligible for a signing bonus for qualified new hires, subject to employment status.
• Conifer observed holidays receive time and a half.

Benefits

Conifer offers the following benefits, subject to employment status:

• Medical, dental, vision, disability, and life insurance
• Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
• For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.