SouthfieldRecruiter Since 2001
the smart solution for Southfield jobs

Clinical Appeals Nurse

Company: Beaumont Health
Location: Southfield
Posted on: March 24, 2020

Job Description:

POSITION TITLE: Clinical Appeals Nurse GENERAL SUMMARY: Responsible for completing retrospective clinical appeals for full or partially denied claims for Managed Care, Government, Non-Government and Commercial payors when the third-party payors do not meet the expected payment as modeled. The Clinical Appeals Nurse will write comprehensive, factual arguments to present to third party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. This position reports to the Manager, Denials. ESSENTIAL DUTIES: Understands the revenue cycle and the responsibility and goals of each area and how their role impacts the system. Analyzes clinical denial/audit review patient medical records, utilizing clinical and regulatory guidelines, and applying knowledge of payer requirements to determine why cases are denied and whether an appeal is required. Utilizes established clinical criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments. Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Collaborates with Case Management, HIM and/or other team members to determine appropriate responses when necessary. Contacts insurance companies to conduct telephonic or electronic appeals, if applicable. Elevates appeals to the appropriate manager/committee when necessary. Provides relevant feedback to applicable departments, related to denial root cause analysis and denial prevention. Ensures compliance with HIPAA regulations, to include confidentiality and integrity as required. Identifies and refers cases appropriately for Case Management, Quality Improvement for education and process improvement. Understands and applies payer specific appeal guidelines and elevates cases for payer peer to peer reviews. Participates in all educational activities and demonstrates personal responsibility for job performance. Maintains a professional image and provides excellent customer service. Attends department meetings and education sessions. Meets/exceeds performance expectations within required timeframes. Practices and adheres to the ---Code of Conduct--- philosophy, Mission, and Values statement. Adheres to all Beaumont Health Policies and Procedures. Performs other duties as assigned. STANDARD QUALIFICATIONS Education / Training: Bachelor---s in science required Associates or bachelor---s degree in Nursing preferred Work Experience : Minimum of two (2) years related experience in health care. Background in Case Management preferred. Knowledge of InterQual or Milliman care clinical criteria Must be familiar with revenue cycle structure and process. Certification, Licensure, Registration : LPN or RN Other Qualifications : Must be detail oriented and must possess excellent time management and organizational skills. Strong verbal and written communication skills. Proficiency in Excel, Word, PowerPoint and Access is necessary Requires critical thinking skills, problem solving, decisive judgment, ability to work with minimal supervision and must possess excellent time management and organizational skills. Must be able to work in a stressful environment and take appropriate action. PC skills- demonstrated proficiency in Microsoft Office applications and others as requires. Policies and Procedures- demonstrates knowledge and understanding of organizational policies, procedures and systems. Basic skills- able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately. Technology skills- requires knowledge of computer systems, operating systems, networks and common software packages available to support database and spreadsheet applications. General knowledge of relevant system support and troubleshooting. Customer orientation- established and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.

Keywords: Beaumont Health, Southfield , Clinical Appeals Nurse, Healthcare , Southfield, Michigan

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Healthcare Jobs


School Social Worker Near Novi, Michigan
Description: A school district in the Novi area has an opening for a School Social Worker The client is in need of a part-time licensed School Social Worker to cover
Company: Soliant Health
Location: Novi
Posted on: 04/7/2020

Registered Nurse (RN) - Emergency Department (ED)
Description: Job DescriptionWe Are Hiring RN-Registered Nurse - Emergency Department 001 - Part-Time,Night - Ascension Providence Hospital, Novi Campus 7p-7a Why Join Ascension In Michigan, Ascension operates 16 (more...)
Company: Ascension, B15
Location: Novi
Posted on: 04/7/2020

PICU Pediatrics Intensive Care Travel RN
Description: Nationwide Travel Nurse Jobs - Pediatric Intensive Care RN Are you looking for a new nursing job Would you like to spend the season somewhere you've never been Hospitals nationwide are looking for (more...)
Company: Travel Nurse Jobs
Location: Royal Oak
Posted on: 04/7/2020


Travel Nurse RN Neonatal Intensive Care (NICU)
Description: Nationwide Travel Nurse Jobs - Neonatal Intensive Care RN Are you looking for a new nursing job Would you like to spend the season somewhere you've never been Hospitals nationwide are looking for qualified (more...)
Company: Travel Nurse Jobs
Location: Redford
Posted on: 04/7/2020

Interventional Cardiology
Description: Requires 3-5 years experience. Call 1:3. Program affiliated with University of Michigan Health System.
Company: MD Doc Jobs
Location: Saginaw
Posted on: 04/7/2020

Travel Nurse RN OR Transplant Surgery
Description: Nationwide Travel Nurse Jobs - Transplant Surgery RN Are you looking for a new nursing job Would you like to spend the season somewhere you've never been Hospitals nationwide are looking for qualified (more...)
Company: HCEN
Location: Royal Oak
Posted on: 04/7/2020

Full-Time School Psychologist (Novi,Michigan)
Description: A detail-oriented, organized, flexible, School Psychologist is desired at a school district with a flourishing student population near Novi, Michigan. The School Psychologist
Company: Soliant Health
Location: Novi
Posted on: 04/7/2020

Registered Nurse RN - Critical Care Unit (SICU)
Description: We Are Hiring RN-Registered Nurse - Critical Care Unit 001 - FT Days 70.2 Hours Biweekly - Ascension St. Mary's - Saginaw, MI7 AM to 7 PM, rotating weekends and holidaysWhy Join Ascension In Michigan, (more...)
Company: Ascension, B48
Location: Saginaw
Posted on: 04/7/2020

Registered Nurse - RN - Progressive Care Unit - PCU
Description: Registered Nurse - RN - Progressive Care Unit - PCUCareerStaff Unlimited is looking to hire a Registered Nurse for full-time, contract opportunities in Metro Detroit, MI. Qualified nurses will have previous (more...)
Company: CareerStaff Unlimited
Location: Royal Oak
Posted on: 04/7/2020

Registered Nurse (RN) - Emergency Department
Description: Job DescriptionWe Are Hiring RN-Registered Nurse - Emergency Department 001 - Full-Time, Night - Ascension Providence Hospital, Novi Campus - Novi,MI 7p-7a Why Join Ascension In Michigan, Ascension operates (more...)
Company: Ascension, B15
Location: Novi
Posted on: 04/7/2020

Log In or Create An Account

Get the latest Michigan jobs by following @recnetMI on Twitter!

Southfield RSS job feeds