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Clinical Appeals Nurse

Halifax Health
Daytona Beach

Job Description

Halifax Health is seeking a Clinical Appeals Nurse.

Summary

The Clinical Appeals Nurse will play an active role in the Revenue Cycle by successfully performing the tracking, resolution, and collection of Clinical Denials and Appeals. The Clinical Appeals Nurse will accurately document into the host system and QMS and supply the Manager of Case Management with accurate work stats. This person will also actively participate in Quality Improvement and process flows.

Job Qualifications

Active Florida RN license, or bachelor degree in related health field or equivalent experience.

Prefer 3-5 years of Case Management, Utilization Review, or hospital business experience in the area of reimbursement methodologies.

Must possess analytical skills.

Prefer some experience in dealing with insurance carriers on disputes and settlement of claims.

Must have knowledge of :

EQ Health/Medicaid rules and regulations;

FMQAI, PEPP;

Cobra and Emtala rules and regulations;

InterQual and Millimen Criteria for utilization review.

Must have an understanding of the billing and collection process as related to healthcare claims.
Must be able to deal effectively with the public and physicians.
Must formulate comprehensive letters and account notes.
Must have good PC knowledge and skills.
Must be able to work successfully in a "team-work" environment.

Job Duties and Responsibilities

Identify clinical denials via fax, correspondence, system worklists, email, hard copy remittance advice and any other data source.
Record clinical denials in the denial tracking database.
Request all materials needed to submit a timely appeal.
Send the appeal in accordance with specific payor guidelines.
Record clinical appeals in the denial tracking database.
Run follow up reports for aggressive follow up, as per policy.
Record final outcomes in the denial tracking database.
Participate in quality improvement for various stages of the Revenue Cycle.
Provide clinical denial statistics to Manager, Case Management and Administration as needed.
Provide clinical expertise and decision making to non clinical staff as needed.
Able to analyze and monitor financial data reports.

About Us

Halifax Health

Recognized by The Joint Commission as a Top Performer on Key Quality Measures, Halifax Health serves Volusia and Flagler counties, providing a continuum of healthcare services through a network of organizations including a tertiary hospital, community hospital, psychiatric services, a cancer treatment center with four outreach locations, the areas largest hospice, a center for inpatient rehabilitation, primary care walk-in clinics, a walk-in clinic specializing in womens health, two community clinics, three childrens medical practices, a home healthcare agency, and an exclusive provider organization. Halifax Health offers the areas only Level II Trauma Center, Comprehensive Stroke Center, Pediatric Intensive Care Unit, Pediatric Emergency Department, Child and Adolescent Behavioral Services, complete Neurosurgical Services, OB Emergency Department and Level II Neonatal Intensive Care Unit that cares for babies born as early as 28 weeks. For more information, visit halifaxhealth.org.

Employment Type

Full-Time

Schedule

Days/1st

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