Clinical Appeals - Rn

Salary Range
$36.72 - $58.60
Overview
Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members.
Employees of Confluence Health receive a wide range of benefits in addition to compensation.

• Generous Retirement Plans
• Tuition Reimbursement
• Long-Term Disability
• Paid Time Off
• Flexible Spending Accounts & Health Saving Accounts
• Adoption Assistance
• Medical, Dental & Vision Insurance
• Life Insurance
• Gym Membership Discount
• Employee Assistance Program
• CH Wellness Program
• Shift Differential

For more information on our Benefits & Perks, click here!
Summary
The Clinical Appeals RN will review and analyze denied and/or downgraded claims received from commercial, private and state payers. This role will utilize nursing and coding expertise to determine whether the claim should be appealed. For all applicable claims the RN will construct a compelling appeal letter based upon current coding guidelines, medical necessity of services rendered, as well as track and trend denial root causes.
Essential Functions

• Ability to write articulate and concise appeals by applying clinical knowledge, coding expertise and medical necessity.
• Ability to detect trends resulting in denials and constructively report on the root cause to assist in resolution and prevention.
• Other duties as assigned.
• Serves as the liaison with government and commercial payers to resolved complex claims, ensure favorable reimbursement, and address other billing or payment issues.
• Manages assigned workload of accounts so that appeals are submitted timely in accordance with payer timeframes.
• Responsible for evaluating likelihood of receiving a favorable resolution of medical necessity denials, payment discrepancies and contract misinterpretations.
• Communicates with the patient access and billing teams as needed to facilitate appropriate actions for recoupment of denied/downgraded claims.
• Collaborates with physicians and interdisciplinary team as appropriate.
• Responsible for clearly documenting actions taken in each patient account.
• Complies with the various payer rules regarding the appeal/denials process.

Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
Position Requirements
Being fully vaccinated against COVID-19 is an essential requirement of working at Confluence Health. Religious and medical exemptions will be considered upon request.
Qualifications
Required:

• Ability to work independently and with limited supervision.
• Proficient with Microsoft Office suite, internet and other systems (CMS, Government & commercial payor portals etc.).
• Two (2) years’ experience in utilization review.
• Analytical aptitude with the ability to collect, analyze and present data effectively.
• Three (3) years of acute care experience or equivalent expertise.
• Strong attention to detail with excellent communication skills in both written and verbal forms.
• Must be a team-player and maintain a positive, resourceful attitude toward achieving the overall departmental and organizational goals.
• Current RN License.
• Ability to communicate changes effectively, build commitment, and overcome resistance.

Desired

• Certified Coding Specialist (CCS).
• Bachelor’s degree.
• 2+ years experience working in the Epic system.

Physical/Sensory Demands
O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday.
F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday.
C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday.
Physical/Sensory Demands For This Position

• Pulling/Pushing: Over 50 pounds - O
• Lifting: 25 pounds to 50 pounds - O
• Carrying: 25 pounds to 50 pounds - O
• Lifting: 25 pounds or less - F
• Pulling/Pushing: 25 pounds to 50 pounds - O
• Bending/Stooping/Crouching - F
• Sitting/Standing - C
• Reaching: Below shoulder height - O
• Carrying: 25 pounds or less - F
• Reaching: Above shoulder height - O
• Lifting: Over 50 pounds - O
• Pulling/Pushing: 25 pounds or less - O
• Walking - C
• Carrying: Over 50 pounds - O
• Crawling/Kneeling - O
• Repetitive Movement - F
• Climbing - O
• Twisting/Turning - O
• Reaching: Shoulder Height - O

Working Conditions

• Work is performed in a normal office environment. Requires a combination of working independently and also working closely with others. Hours may be irregular at times. May require travel to other CWH & C, WVH & C and CH locations. Requires building relationships and frequent contact with other departments throughout the organization.

Job Classification

• Hourly/Salary: Hourly
• FLSA: Non-exempt

Physical Exposures For This Position

• Ionizing/Non-Ionizing Radiation – No
• Lighting – No
• Infectious Diseases – Yes
• Heat – No
• Noise – No
• Hazardous Substances – Yes
• Mechanical Hazards – Yes
• Blood Borne Pathogens Exposure Potential – Yes
• Unprotected Heights – No
• Cold – No