XTN-31A1288 | PHRN – CLINICAL DENIALS AND APPEALS

The PHRN - Clinical Denials and Appeals is responsible for reviewing and addressing medical necessity and authorization-related claim denials by conducting thorough clinical reviews, preparing appeal letters, and communicating effectively with payers. This role involves analyzing Explanation of Benefits (EOBs), identifying root causes of denials, and utilizing payer portals to resolve issues efficiently. The nurse supports revenue cycle operations by ensuring timely and accurate appeal submissions, contributing to improved claim outcomes and reduced financial losses for the organization.

• Health Insurance/HMO 
• Enjoy unlimited MadMax Coffee
• Diverse learning & growth opportunities
• Accessible Cloud HR platform (Sprout)
• Above standard leaves

• Effectively review inpatient and/or outpatient medical necessity and authorization denials to determine and understand the validity of such denials in a timely manner Should conduct comprehensive reviews of the claim denial and account, to make determinations of what action to be taken to obtain reimbursement.
• Utilize payer policies, MCG and InterQual criteria to determine if account meets criteria for appeal
• Should write an appeal letter to payer using appropriate clinical indicators, citing Official Coding Guidelines, and documentation from within the patient's medical record
• Perform all other necessary steps on the specified accounts per Clients SOP’s including documentation in the EMR, including appeal package creation Manage the accounts until payment is received, the account is written-off, transferred to patient-liability, or other adjudication / movement within the system that is appropriate and agreed upon by both Parties
• Reporting quality results, tracking and trending of educational opportunities of the coding and CDI specialists, responding to client subject matter needs, and providing educational support and training

• PH Registered Nurse with experience in doing medical necessity appeals, lack of authorization appeals.
• Proficient in reading Explanation of Benefits (EOB) and investigating denial root causes.
• Must be skilled in navigating various payer and provider portals.
• Typing speed of at least 45 WPM.
• Strong command of the English language, both spoken and written.
• Willing to work night shifts to communicate with payers.
• Familiarity with MCG and InterQual is a plus.
• Must NOT hold a USRN license