Denials Nurse-Potential Work from Home in Johnstown, PA at Health Support Center

Date Posted: 5/23/2018

Job Snapshot

Job Description

Health Support Center

Job Summary  

Responsible for completing retrospective clinical appeals for full or partially denied claims for Government and Commercial payors. The Clinical Appeals Nurse develops comprehensive, factual arguments to present to third party payors, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity.

Essential Functions

  1. Analyze clinical denials daily from the denial work queue reviewing patient medical records, utilizing clinical and regulatory guidelines, and applying knowledge of payor requirements to determine why cases are denied and whether an appeal is required, applying payor specific appeal guidelines
  2. Utilizes established clinical criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments searching for supporting clinical evidence to support appeal arguments when existing resources are unavailable 
  3. Collaborates with Case Management, HIM and/or other teams to determine appropriate responses when necessary
  4. Contacts insurance companies to conduct telephonic appeals, if applicable
  5. Identifies and refers cases appropriately to Case Management and Quality Improvement for education and process improvement 

Job Requirements

  • Licensed Practical Nurse or Registered Nurse required
  • Associates degree preferred
  • Minimum of two (2) years related experience in health care, with familiarity with revenue cycle processes preferred.
  • Background in Case Management preferred 
  • Proficiency in Microsoft Office applications required

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran