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Remote Clinical Appeals Nurse
|Company:||Convergent||Location:||Boca Raton, Florida, United States|
|Posted:||Wednesday, June 20, 2018|
Appeals Nurse/ Nurse Auditor (Part Time Remote)
Part Time Position: 20+ hours per week
Reporting to Boca Raton, FL Location
This is an ideal opportunity for a healthcare professional looking for remote work as the successful candidate can work anywhere in the country and report to our Boca Raton, FL office.
Convergent employs a dedicated team of expert Healthcare Attorneys, Account Specialists and Clinicians who navigate the entanglements of the legal system to increase reimbursement rates for our client hospitals all over the country. 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.
- Serve as a clinical resource, provide clinical expertise, and clinical guidance to the team, as well as our client hospitals.
- Work with company’s Attorneys and Account Specialists to overturn claims denied by Commercial insurers, Medicare, Medicaid, and other third-party payers.
- Conduct medical chart reviews by reviewing all clinical documentation. Clinically validate the medical appropriateness, and coding accuracy, of services rendered in both inpatient and outpatient settings.
- Create narrative rationale in response to audit and chart review determinations
- Craft and submit medical necessity and clinical appeals that get denials overturned, as well as provide guidance to attorneys to write winning appeals.
- Review clinical polices and guidelines, i.e. NCD/LCD coverage documents, carrier specific policies related to investigational or experimental procedures, and readmissions.
- Perform chart audits to validate charges as they relate to the services rendered, based on medical documentation
- Maintain current knowledge of Medicare and Commercial Insurance trends, regulations, and policies.
- 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.
- Experience in defending government audits such as RAC.
- Experience/Knowledge in all clinical areas, both inpatient and outpatient, including but not limited to, Cardiology, Pediatrics, Medical Surgical, Trauma and E.R., Cancer, and Behavioral Health.
- 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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