XTN-43C2964 | PHRN CLINICAL DENIALS AND APPEALS NURSE (PHRN)

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The main responsibilities of a PHRN Clinical Denials and Appeals Nurse (PHRN) include:

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