Clinical Appeal Nurse - Remote
: Job Details :

The Revenue Cycle Clinician for the Appellate Solution is responsible for:a) Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review b) Preparing and documenting appeal based on industry accepted criteria. ESSENTIAL DUTIES AND RESPONSIBILITIES - Include the following. Others may be assigned. Performs retrospective (post discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. Demonstrates proficiency in use of medical necessity criteria sets, currently Inter. Qual or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of Inter. Qual criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinen...Clinical, Nurse, Healthcare, Remote, Medical, Accounting