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Clinical Appeals Nurse- State of Florida (Remote)
|Company:||Convergent||Location:||Boca Raton, Florida, United States|
|Posted:||Monday, January 22, 2018|
Convergent’s Boca Raton FL Insurance Department has openings for a Clinical Appeals Nurse based in the State of Florida. This is an ideal opportunity for a healthcare professional looking for remote work as the successful candidate can work anywhere in the state of Florida and report to our Boca Raton, FL office.
Convergent employs a dedicated team of expert Healthcare Attorneys, and Account Specialists and Clinicians who navigate the entanglements of the legal system to increase reimbursement rates for our client hospitals all over the country. We apply our advanced technology to calculate anticipated payment for claims in states with complex fee schedules, allowing us to accurately identify and appeal underpaid or denied claims. Our main goal is to assist hospital systems to strengthen their financial and clinical performance. We are also a leading provider of denial management, Workers' Compensation claims resolution, and appeals solutions.
Resumes will not be considered if you do not provide desired salary information.
- Works with company’s Attorneys and Claims Representatives/Account Specialists to overturn claims denied by Commercial insurers, Medicare, Medicaid, and other third-party payers based upon medical necessity and other clinical reasons.
- Reviews physician documentation and other medical documentation for appropriateness of hospitalization in order to support medical necessity and level of care appeals
- Prepare and submit appeals to third party payers to recover payments when needed
- Remain current on applicable UR trends and regulations
- Provide ongoing training and feedback to company’s non-clinical staff members, as well as act as a consultant to client hospitals where needed.
- Perform other related duties as required
- Licensed RN –license must be active, and in good standing.
- Two to five years as a Clinical Appeals Nurse with a main focus on recovering payment for hospitals.
- Must be able to craft and submit medical necessity and clinical appeals that get denials overturned
- Experience/Knowledge in all clinical areas, such as Cardiology, Pediatrics, Medical Surgical, Trauma and E.R., Cancer, Behavioral Health, Utilization Review and other cost management programs required.
- Experience using InterQual criteria or Milliman criteria required.
- Experience reviewing clinical polices and guidelines, i.e. NCD/LCD coverage documents, carrier specific policies related to investigational or experimental procedures.
- Experience in an acute care hospital preferred (this can be hospital-based case management either from onsite at a hospital, or on the insurance side doing hospital reviews)
- Strong problem solving and decision making skills essential.
- Strong typing and computer skills essential.
- Excellent verbal and written communication skills; ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
- Team Player - works well as a member of a group
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