[Hiring] Clinical Reviews, Denial and Appeals RN @Texas Health Resources

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description This role involves managing clinical reviews, denials, and appeals within a remote work environment. • Communicates and collaborates with physicians, Care Management staff, Business Office, Nursing, and ancillary departments to address patient care issues and denials management • Conducts research for appealing denied days/stays through electronic record review • Collaborates with physicians to develop appeal strategies for medical necessity denials • Reviews clinical documentation to determine if medical necessity criteria were met • Prepares appeal letters and notifications within specified time frames • Tracks, monitors, and manages clinical denials and appeals • Reports denial trends for educational corrective action • Develops and maintains relationships with other departments related to appeals and denial management • Serves as an educator and resource regarding Medicare, Medicaid, and Commercial payer guidelines • Reviews Medicare one day stays and conducts medical necessity internal audits Qualifications • Associates Degree in Nursing required • Bachelor’s Degree in Nursing preferred • 3 years Inpatient clinical nursing experience in an acute hospital setting required • 1 year UM experience including knowledge and application of Milliman or InterQual criteria required • Case management experience preferred • Denials and Appeals experience preferred • RN license to practice in the state of Texas upon hire required Benefits • 401k • PTO • Medical and dental insurance • Paid Parental Leave • Flex spending • Tuition reimbursement • Student Loan Repayment Program • Additional benefits available Company Description At Texas Health Resources, our mission is “to improve the health of the people in the communities we serve”. • Award-winning culture recognized by FORTUNE Magazine’s “100 Best Companies to Work For®” for the 9th year in a row • Committed to diversity in our workforce • Strives to create an atmosphere of respect, integrity, compassion, and excellence Apply tot his job