Employment Type:

Full time

Shift:

Description:

Trinity Health, Mid-Atlantic, is looking for a Clinical Appeals Specialist Nurse to join our Central Appeals team!



Shift: Full-Time, days
Location: After initial orientation and training, this position will be remote.



Under the supervision of the THMA Central Appeals Unit Physician Advisor and Manager/Supervisor, Central Appeals Unit, the Central Appeals Specialist (CAS) RN is responsible for drafting appeal, reconsideration and dispute letters for retrospective (post-discharge) denials or audit downgrades of acute inpatient / observation admissions, readmissions within 30-days, downgrades from Inpatient to Short Procedure Unit, DRG downgrades for inpatient level of care & clinical validation of diagnosis code removal.

• Utilize peer-reviewed medical literature , Payer contract Medical Necessity definition of Inpatient and government guidelines for reasonable and medically necessary Inpatient Admission to support the appeal.

• M ay be responsible for sending the appeal letter and pertinent appeal documents to the Payer or Auditor.

• May be responsible for follow up on appeal decisions.

• Investigates and responds to appeals and denials in accordance with requirements of managed care payer contracts, federal and state laws, and department policies regarding quality, productivity and timeliness through review of documentation, charges, and criteria.

• Manage appeal activity in Veracity and EPIC in accordance with department and THMA policy, review medical records in legacy Meditech and Midas.

Requirements:

• BSN (required)
• Active and unencumbered PA RN License (required)
• 3-5 years of clinical nursing experience (preferred)
• 2-5 years of payer or provider utilization or case management experience in a hospital or managed care environment (preferred)

We offer a competitive salary and comprehensive benefits including:

• Medical, Dental, & Vision Coverage
• Retirement Savings Program
• Paid Time Off
• Tuition Reimbursement
• Free Parking
• And more!

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.