Clinical Appeals RN

Clinical Appeals Nurse The Clinical Appeals Nurse is responsible for investigating and processing medical necessity appeals from members and providers to payers. Possesses the ability to conduct research on standards or practice, regulations, and policy relevant to any case. Responsible for overturning denied claims, upholding the denials and submitting cases to the Medical Director for review. Possesses the ability to communicate clearly and concisely, both verbally and in writing and utilize computer and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Ensures timely and accurate processing of all denials. Will ensure that denials are processed according to KPC Policies and meet all Health Plan, Federal and State requirements. Perform other duties as assigned.Requirements:Current active California RN license requiredMinimum 2 years of experience in a managed care healthcare settingMinimum 2 years of Utilization ManagementExperience with payer specific medical guidelines and how to apply them in an appealExperience using MCG and/or InterQual guidelinesDuties and Responsibilities:Conduct and investigate member and provider medical necessity appealsReview prospective, inpatient, and retrospective medical records of denied services for medical necessityEnsures appeals and grievances are resolved in a timely mannerPrepare clinical reviews and provides monitoring of cases involving medical decisions and quality of services and careGenerate written correspondence to providers and members to achieve maximum overturn rateProvide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisionsPrepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information receivedPresents recommendations based on clinical review, criteria, and organizational policiesComplies with HIPAA and other compliance requirements to protect patient confidentialityContact and educate patients and guarantors regarding necessary steps to resolve an outstanding insurance balance while providing exemplary customer service