Huron is a global professional services firm elevating the vision of what's possible and then putting it into practice.
Nurse Specialist – Clinical Denials and Appeals
Location
Illinois
Posted
9 days ago
Salary
$33 - $43 / hour
Seniority
Senior
Job Description
Nurse Specialist – Clinical Denials and Appeals
Huron
• Responsible for reviewing the claims denied and carrying out the appeals process appropriately and in a timely manner • Identifies and works denials, responding to the denial reason and resubmitting any information needed to the payor • Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing the clinical documentation, assessing options and completing next steps • Submit retro-authorizations in accordance with payor requirements in response to authorization denials • Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals. • Write and submit written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language • Document all actions taken and follow-up timely as needed related to resolving denials and appeals with third-party payers in a timely manner • Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms • Complies with state and federal regulations, accreditation/compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA
Job Requirements
- At least 1 year of clinical appeal writing experience
- Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years if ICU experience
- Associate Degree in Nursing (ADN) or Diploma in Nursing
- Must be Registered Nurse with an active USRN license
- Proficiency in using InterQual or MCG clinical guidelines
- Broad Knowledge of U.S. Government Programs and Insurance Regulations
- Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech
- Case management or clinical appeals or clinical denials certification (ACMA) is preferred.
- Proficiency with Microsoft office suite (Excel, Word, PowerPoint, Outlook, SharePoint)
Benefits
- Medical, dental and vision coverage
- Employee stock purchase plan
- 401(k) plan with a generous employer match
- Paid Time Off policy
- Paid parental leave and adoption assistance
- Free annual health screenings and coaching
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