Denials Management Appeals Nurse (Anesthesia)

The Denials Management Appeals Nurse (Anesthesia) manages medical denials by reviewing clinical documentation and filing appeals, utilizing clinical expertise to address and resolve insurance and governmental payor denials.

Location: United States

Responsibilities

• Performs a review of assigned cases comparing the bill to the medical record.
• Performs a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process.
• Performs a detailed comparison of charges to documentation to ensure services not documented are not charged.
• Reviews documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur.
• Review findings with the hospital representatives and obtains an agreement on the discrepancies.
• Demonstrates tact and understanding in handling problems, has a good rapport with hospital and corporate staffs.
• Follows up on appeals in a timely fashion to ensure that cases are completed.
• Re-checks mathematical computations before finalizing letter and report.
• Updates status of all cases assigned on minimum weekly basis.
• Informs supervisor of any changes, problems, or concerns that arise at a facility.
• In the event of a dispute with the requesting party’s audit findings, files an appeal with the third party or governmental payor.
• Analyzes and interprets all medical necessity/clinical denials from third party payors or governmental payors.
• Files appeals based on medical documentation and interpretation of medical necessity guidelines or InterQual criteria.

Requirements

• 5 years of clinical healthcare/hospital experience
• 3 years of related Anesthesia experience
• Third Party Payor Appeals/Revenue Cycle experience
• Current RN license in State of employment
• Working experience with Utilization Review activities and general knowledge of TJC, PRO, and other regulatory bodies.

Benefits

• All employees are eligible for medical coverage on their first day.
• Eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service.
• Employees in a FT or PT status are eligible for paid time off, life insurance, short term and long-term disability, FSA plans, and HSA if a HDHP is elected.
• Additional benefits include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance, and more, with coverage available to employees and dependents.

Additional Information

• This is not an all-inclusive list of responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned.