Rn Appeals Analyst Remote Work From Home

At Elara Caring, we have an unique opportunity to play a huge role in the growth of an entire home care industry. Here, each employee has the chance to make a real difference by carrying out our mission every day. Join our elite team of healthcare professionals, providing the Right Care, at the Right Time, in the Right Place.

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The Registered Nurse Appeals Analyst performs medical record reviews to determine the quality of care, identifies quality issues, and assures compliance with medical record standards and regulatory mandates as related to billing compliance. The incumbent analyzes submitted claims and/or claims to be submitted as well as medical records to determine benefit coverage for medical services under review. This position educates providers on all aspects of medical record criteria to determine benefit coverage for medical services. This position prepares written documents and/or reports of completed medical review determinations and submits records to the payer, as requested.

At Elara Caring, we care where you are and believe the best place for your care is where you live. We know there’s no place like home, and that’s why our teams continue to provide high-quality care to more than 60,000 patients each day in their preferred home setting. Wherever our patients call home and wherever they are on their health journey, we care. Each team member has a part to play in this mission. This means you have countless ways to make a difference as an Appeals Analyst by keeping a team of elite healthcare professionals operational.

To continue to be an industry pioneer delivering unparalleled care, we need a Appeals Analyst who shares our commitment to distinction and progress. Are you one of them? If so, apply today!

As an Elara Caring Appeals Analyst, you’ll contribute to our success in the following ways:

• Ensures that all activities performed align with the vision of Elara Caring’s board of directors, executive team, and the leadership of the Compliance team.

• Communicates with agencies related to documentation needs in a timely manner and follows up with agency leadership, as needed.
• Participates in Administrative Law Judge hearings as the company expert.
• Writes business letters and reports to explain determinations and decisions to a variety of audiences, including, but not limited to governmental payers, private insurance providers, and administrative law judges.
• Educates providers on all aspects of medical review criteria.
• Promotes, coordinates, and evaluates operational Systems to enhance operations and promote efficiencies.
• Participates in all levels of appeal, using regulatory guidance and critical thinking to navigate appeals compliantly.
• Participates in the development of strategies/education to prevent loss of revenue during recovery audits.
• Conducts audits, as needed to ensure documentation adequacy.
• Practices and adheres to departmental, state, and national guidelines.
• Provides leadership to team and support staff in identifying agency/client needs and opportunities for improvement.
• Performs other duties/projects as assigned.
• Communicates significant findings, problems, and changes related to compliance with documentation standards to the director and other personnel involved with patient care.
• Promotes Elara Caring’s philosophy, mission statement and administrative policies to ensure quality of care.
• Collaborates with providers to adhere to clinical standards of care to ensure appropriate outcome.
• Maintains patient and staff privacy and confidentiality pursuant to HIPAA Privacy Final Rule.
• Collects appropriate medical records, reviews the documentation for validity, and submits the requested documents for pre-claim reviews, ADR requests, and/or appeals.
• Provides education related to audit trends and denials.
• Identifies and communicates to Governmental Review Manager and other supervisory personnel visit documentation that lacks adequate content to support billing guidelines.
• Participates in the appeals process for claims denied by the government or other payers, as necessary.
• Promotes compliance with all regulatory standards, through review of medical records.
• Assists with development of staff education tools/guides to promote appropriate clinical documentation and utilization.

Why Join the Elara Caring mission?

• Opportunities for advancement
• You’ll work in a collaborative environment
• You’ll be rewarded with a unique opportunity to make a difference
• Outstanding compensation package
• 401K match and paid time off for full-time staff
• Fleet vehicles available, per company policy
• Comprehensive onboarding with mentorship and preceptor support Ongoing Continuing Education (CEs) available at no cost
• COVID-19 Prepared with Personal Protective Equipment and precautions
• Medical, dental, and vision benefits after 30 days of employment

What is Required?

• Demonstrated knowledge in all levels of home health, hospice, palliative, and home medical equipment practices
• Demonstrated communication, organizational, analytical, problem-solving, and negotiation skills
• Ongoing understanding of current Medicare, Medicaid, and third-party regulations as changes occur
• Prior functional working experience in medical records review arena (Utilization Review, Case Management and knowledge of appropriate billing and coding guidelines) is required
• Current license as a Registered Nurse is required
• 3 years of experience as a registered nurse in a home health and/or hospice clinical care setting is required
• Bachelor’s degree in Nursing is preferred

You will report to the Governmental Review Manager.

This is not a comprehensive list of all job responsibilities ; a full job description will be provided.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace.