Appeals and Grievance Registered Nurse II - TLRA Clinical Appeals

DescriptionSummary: Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility. Responsibilities: Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal servicesReview governmental contractors response letter in comparison to the medical recordsCommunicates with facility regarding missing or insufficient medical documentationReview medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services providedResearch issues using federal or law, federal regulations, and relevant CMS policies Communicates with members of the healthcare team identifying root causes for potential denialsCommunicates with the CMO/VPMA regarding appeals and obtain signature for appealsAssures all discussions and appeals are filed timelyCompletes data entry in the Denial database for tracking, trends, and analysis Requirements: Associate's Degree in NursingRN License in state of employment or compact Work Type: Full Time EEO is the law - click below for more information:  https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at (844) 257-6925. Additional Information: - Specialty: RN - Location: 2900 North Loop WestHouston, Texas 77092 - Contact: About the Company: CHRISTUS Health is an international Catholic, faith-based, not-for-profit health system comprised of more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. Sponsored by the Sisters of Charity of the Incarnate Word in Houston and San Antonio and the Sisters of the Holy Family of Nazareth, the mission of CHRISTUS Health is to extend the healing ministry of Jesus Christ. To support our healthcare ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on staff who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States. EXTENDING THE HEALING MINISTRY OF JESUS CHRIST We are inspired by our mission, vision and core values to deliver compassionate, high quality health care, improving the health of the communities we serve. Above all, we are committed to providing our customers and their family members with a truly unique healing experience, one that embodies our values and respects the dignity and worth of each person. Creating a health care system that is truly excellent in all areas is an ongoing effort.