Rn Appeals ( Remote Position)

Req #: 0000104861

Category: Nurse Case Manager

Status: Full-Time

Shift: Day

Facility: RWJBarnabas Health Corporate Services

Department: Appeals

Location:

SBC Corporation, 2 Crescent Place, Oceanport, NJ 07757

Job Summary

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 be detail-oriented with strong critical thinking and organization skills.
• Proficiently read and understand abstract information from handwritten patient medical records.
• Ability to work independently, meet deadlines, troubleshoot, and present findings.
• Must have proficiency with online nationally recognized UM criteria, including Milliman Care Guidelines (MCG) and/or InterQual (IQ).
• Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appeal process.
• 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 proficiency in utilization of electronic tools including but not limited to Microsoft Office.
• 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.
• Ensure compliance with HIPAA regulations, to include confidentiality, as required.
• 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.

Minimum Qualifications & Competencies

• Medical-surgical/critical care experience preferred.
• Minimum of 2 years UR/UM/CM.
• 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.
• Must possess MCG UM Certification or obtain within 6 months of employment.

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.

Additional Information

We offer a great work environment, competitive rates and excellent benefits, including:

• Tuition Reimbursement
• Short & Long Term Disability
• Medical/Dental/Vision plans
• 401 (k)
• Vacation/Personal/Holiday/Sick Time Off
• Health Care/Dependent Care Flexible Spending Accounts
• Basic Life & Accidental Death Insurance

RWJBarnabas Health is an Equal Opportunity Employer