Appeals Specialist Nursing Hours: M-F 8AM - 4:30PM Days - Full-time Paygrade/Wages/Salary Info: 75BH -
Job Summary Responsible for denial management on all governmental and commercial payers, including inpatient and outpatient claims. # Job Responsibilities Conducts chart audits to determine most appropriate course of action when payer denial received. Composes credible appeal letters, utilizing: Federal and State regulations; Center for Medicare and Medicaid (CMS) Guidelines and policies; Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS) payment; ICD-10M Official Guidelines for Coding and Reporting; AHA Coding Clinics; InterQual Medical Necessity criteria; Current Procedural Terminology (CPT) Guidelines; Medical Standards of practice; and published articles, journals and clinical studies. Collaborates extensively with Business Office/HIM/Auditing/Finance/Medical Director of Case Management/and others as appropriate in order to obtain resolution of denial. Effectively researches each case in search of data necessary to decide if case warrants appeal. Identifies and reports trends and issues to stakeholders. Examines the reason for denial and looks for inconsistencies inside of the option. Maintains up-to-date knowledge of CMS regulations and appeal rights. Enters accurate data related to the appeal process into system databases. Qualifications Associate#s degree or higher or Diploma in Nursing required upon hire AND Bachelor#s degree or higher in Nursing required within 5 years of employment in this position A minimum of 2 years# relevant experience required RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire Skills and Attributes Requires critical thinking skills and decisive judgment. Works under minimal supervision. Must be able to work in a stressful environment and take appropriate action. Physical Demands Standing: Occasionally Walking: Occasionally Sitting: Frequently Lifting 0-25 lbs: Rarely Lifting 25-75 lbs: Never Lifting over 75 lbs: Never Carrying 0-25 lbs: Rarely Carrying 25-75 lbs: Never Carrying over 75 lbs: Never Pushing/Pulling 0-25 lbs: Rarely Pushing/Pulling 25-75 lbs: Never Pushing/Pulling over 75 lbs: Never Climbing: Rarely Bending/Stooping: Rarely Kneeling: Rarely Crouching/Crawling: Rarely Reaching: Occasionally Talking: Frequently Hearing: Occasionally Repetitive Foot/Leg Movements: Never Repetitive Hand/Arm Movements: Frequently Keyboard Data Entry: Frequently Running: Never Vision: Depth Perception: Frequently Vision: Distinguish Color: Frequently Vision: Seeing Far: Frequently Vision: Seeing Near: Frequently Owensboro Health Core Commitments INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers. RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community. TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future. INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health. SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do. EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.