Clinical Appeal Nurse Lead

Major Responsibilities:

• Responsible for training, evaluating and staffing coverage for Revenue Recovery.
• Performs quality review process audits and staff feedback. Ensures acceptable productivity levels and assigned tasks/appeals are completed
• Identify process inefficiencies and opportunities for daily workflow improvement and participate in developing new processes with Revenue Recovery Manager.
• Keeps abreast of current standards, regulations, and issues related to denials and Revenue Recovery including but not limited to, Government and Insurance Payer reimbursement regulations, clinical practices, utilization management, process improvement and health care industry trends via literature, educational offerings, federal register, etc.
• Maintains an effective working relationship with both internal and external customers.
• Act as a resource for new payer requirements. Participate in monthly Payer meetings, gathers data and reports issues/discrepancies
• Monitors and manage daily reports to ensure timely appeals per payer requirements.
• Investigate and respond to questions from other departments, physicians, payers, and patient related to insurance denials.
• Perform clinical denial review and appeals as needed based on coverage needed. Ensure personal and staff productivity goals are met or exceeded.
• Performs human resources responsibilities for staff which includes coaching on performance, completes performance reviews and overall staff morale. Recommends hiring, compensation changes, promotions, corrective action decisions, and terminations.
• Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization's business.

Licensure:

• Nurse, Registered (RN)

Education/Experience Required:

• Bachelor's degree in Nursing

Knowledge, Skills & Abilities Required:

• Solid knowledge of third-party health care insurance plans, denials and appeals procedures.
• Solid knowledge of utilization/denial management and managed care.
• Knowledge of CMS and other regulatory requirements.
• Understanding of process improvement.
• Demonstrated flexibility, teamwork, and system thinking.
• Proven understanding and analyzing patient bills and medical records. 
• Knowledge of government and nongovernment clinical denial and appeal procedures
• Excellent relationship building skills.
• Excellent written and verbal skills.

Physical Requirements and Working Conditions:

• This position requires travel, therefore, will be exposed to weather and road conditions.
• Operates all equipment necessary to perform the job.
• Exposed to a normal office environment.