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Clinical Appeals Nurse
JeffersonClinical Appeals Nurse reviewing payor appeals and coordinating claim processes for Jefferson Health. Acting as a liaison with external payors to ensure compliance and documentation standards.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in reviewing payor denials and conducting appeals, utilizing clinical criteria to establish medical necessity. Proficient in coordinating with third-party payors and ensuring compliance with regulatory requirements while maintaining accurate documentation.
Highest-signal resume keywords
Clinical Criteria ApplicationPayor Denial AppealsUtilization ReviewInterqual KnowledgeEpic Workflow Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Chart ReviewDocumentation Deficiency IdentificationCoding for Payment of ClaimsRevenue Loss IdentificationAppeal Letter WritingPatient Record CoordinationInsurance KnowledgeRegulatory ComplianceExcel ProficiencyMS Word Proficiency
Soft Skills
AdaptabilityCommunicationCollaboration
Tools & Technologies
Epic
Certifications & Qualifications
RN - Licensed Registered NurseRCE Training
Industry Keywords
Case ManagementUtilization ReviewHospital LiaisonPayor Trends MonitoringMedical Policy Guidelines
About the role
Key responsibilities & impact- Reviews payor denials and audits for potential lost revenue
- Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity
- Functions as a hospital liaison with external third-party payors to appeal denied claims
- Works closely with Physician advisor team to facilitate appeals to payors
- Monitors and reports payor trends to management team
- Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor
- Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor
- Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials
- Contacts insurance companies and conducts appeals via telephone or email
- Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights
- Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors
- Ensures that all appeals are sent to the correct payor within the appeal guidelines
- Ensures compliance with regulatory and accrediting requirements
- Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor
- Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable
Requirements
What you’ll need- Bachelor’s Degree Nursing or Specialized Diploma
- 10 years of clinical or case management/utilization review experience
- Ability to read medical charts and identify deficiencies in documentation content
- Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes
- Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures
- Knowledge of coding for payment of claims
- Insurance knowledge of payors and their unique rules
- Epic workflow experience with notes in account history and WQ workflows
- Intermediate Excel and MS Word experience
- Must complete RCE Training and pass test with 80% or better
- RN - Licensed Registered Nurse_PA - State of Pennsylvania
Benefits
Comp & perks- medical (including prescription) insurance
- supplemental insurance
- dental insurance
- vision insurance
- life and AD&D insurance
- short- and long-term disability
- flexible spending accounts
- retirement plans
- tuition assistance
- tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service