Appeals Nurse

Job description

Ready to help us transform healthcare? Bring your true colors to blue. Job Profile: Appeals Nurse Reviewer: Job Code: HCM101 Business Title: Appeals Nurse Reviewer Reports To: Patricia Corsini RN, BSN The Role: The Clinical Appeals Nurse Reviewer facilitates, coordinates, and responds to provider appeals for denied services utilizing extensive clinical, regulatory, business, and coding knowledge. Collaborates with the Physician Review Units, Medical & Payment Policy Departments, Provider Service, Member Service and Claims Area to research and resolve provider claims appeals. The Team: As an integral part of the Clinical Appeals team, the Appeals Nurse Reviewer will serve as a liaison and business expert for claims appeals. This role works collaboratively with Provider Service, Claims, Network Management, Physician Review, and Medical and Payment Policy teams. Key Responsibilities: Review appeals utilizing sound clinical judgement, medical policy, payment policy guidelines, pricing files, contractual obligations, and billing practices, all to appropriately adjudicate provider and facility claims appeals Use comprehensive knowledge of coding guidelines to approve or reject payment fo...