Clinical Appeals

Job Overview:

Our Denial Management Recovery Services division is an integral part of our company's success. The RN of Appeals within the RWJ Barnabas healthcare facilities is responsible for managing medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted the Appeal Clinician will write sound compelling factual argument correspondence. The Clinician will construct and document a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts. Pertinent clinical facts include but are not limited to documentation preventing a safe transfer/discharge/transition of care or documentation of medically necessary services denied for lack of authorization.

Core duties and responsibilities include the following:

• Must have proficiency with online nationally recognized UM criteria including Milliman Care Guidelines (MCG) and/or InterQual (IQ).
• Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
• Demonstrates ability to critically think problem solve and make independent decisions supporting the clinical appeal process.
• Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts. Pertinent clinical facts include but are not limited to documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Prepare convincing appeal arguments using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments. Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
• Proficiently read and understand abstract information from handwritten patient medical records.
• Ensure compliance with HIPAA regulations to include confidentiality as required.
• Demonstrates proficiency in utilization of electronic tools including but not limited to Microsoft Office.
• Ability to work independently meet deadlines troubleshoot and present findings.
• Must be detail-oriented with strong critical thinking and organization skills.

Qualifications:

Required:

• Must possess a valid nursing license (Current valid RN/LPN/LVN licensure)
• Minimum of 5 years recent acute care experience with the last 2 years in a facility environment
• Minimum of 2 years UR/UM/CM

Preferred:

• Medical-surgical/critical care experience

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities duties or responsibilities that are required of the employee for this job. Duties responsibilities and activities may change at any time with or without notice.

Benefits and Perks:

At RWJBarnabas Health our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical emotional social and financial health.

• Paid Time Off (PTO)
• Medical and Prescription Drug Insurance
• Dental and Vision Insurance
• Retirement Plans
• Short & Long Term Disability
• Life & Accidental Death Insurance
• Tuition Reimbursement
• Health Care/Dependent Care Flexible Spending Accounts
• Wellness Programs
• Voluntary Benefits (e.g. Pet Insurance)
• Discounts Through our Partners such as NJ Devils NJ PAC Verizon and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered high-quality academic medicine in a compassionate and equitable manner while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities one person and one community at a time. As the leading academic health system in New Jersey we advance innovative strategies in high-quality patient care education and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

Equal Opportunity Employer