Clinical Appeals, RN, Full time, Remote, NJ at RWJBarnabas Health – Oceanport, New Jersey

Job Overview:

Our Denial Management Recovery Services division is an integral part of our company's success. The RN of Appeals within the RWJ Barnabas healthcare facilities is responsible for managing medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Appeal Clinician will write sound, compelling factual argument correspondence. The Clinician will construct and document a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge/transition of care or documentation of medically necessary services denied for lack of authorization.

Core duties and responsibilities include the following:

• Must have proficiency with online nationally recognized UM criteria, including Milliman Care Guidelines (MCG) and/or InterQual (IQ).
• Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
• Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appeal process.
• Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts. 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.
• Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments. Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
• Proficiently read and understand abstract information from handwritten patient medical records.
• Ensure compliance with HIPAA regulations, to include confidentiality, as required.
• Demonstrates proficiency in utilization of electronic tools including but not limited to Microsoft Office.
• Ability to work independently, meet deadlines, troubleshoot, and present findings.
• Must be detail-oriented with strong critical thinking and organization skills.

Qualifications:

Required:

• Must possess a valid nursing license (Current, valid RN/LPN/LVN licensure)
• Minimum of 5 years recent acute care experience with the last 2 years in a facility environment
• Minimum of 2 years UR/UM/CM

Preferred:

• Medical-surgical/critical care experience

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.