Clinical Appeals Specialist PD

SUMMARY:

The Clinical Appeals Specialist reports to the Manager Appeals. Under general supervision and within Brown University Health policies and procedures, works collaboratively with The Miriam Hospital and Rhode Island Hospital and multiple system-wide departments. Is responsible for review of medical records to ascertain appeal information and for the development of appeal correspondence. Analyzes clinical denials based on severity of illness and intensity of service using InterQual criteria and Center for Medicare and Medicaid Services (CMS) guidelines. Analyzes and reports data of audits at the facility and system-wide level. Provides education to Brown University Health staff and physicians to reduce future audit exposure.
Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

RESPONSIBILITIES:

• Is responsible for the hospitals appeals initiative by coordinating governmental and third party appeals with attending physicians and the medical director. Collaborates with government oversight agencies and third-party payers regarding audits.

• Prepares, reviews, develops and maintains various manual and computerized documentation. Records and reports vital statistics on the denials and appeal data. Ensures completeness and accuracy.

• Prepares and presents high level professional presentations. Participates on various hospital, state and department committees to provide input for development of policies and procedures related to audits and appeals.

• Participates in ongoing, independent study, education-related professional activities and affiliations to maintain knowledge of government and commercial payer regulations and reimbursement issues.

• Researches and identifies opportunities for improvement and submits recommendations to manager and/or director.

• Conducts retrospective reviews and audits of hospital records to determine if level of care is appropriate and sufficiently documented Works collaboratively at all levels of the organization.

• Participates in or leads various committees, task forces and quality improvement teams as needed. Performs other duties as assigned.

MINIMUM QUALIFICATIONS:

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

BASIC KNOWLEDGE:

Must have current licensure to practice as a Registered Nurse in the State of Rhode Island.

Bachelor's Degree in Nursing, Health Science or Health Business required, Master's Degree preferred.

EXPERIENCE:

• Three years or more of relevant recent clinical and/or administrative experience in medical/surgical nursing;

• two years of which must be related to utilization review activities, demonstrating organizational skills and ability to make sound clinical judgment.Working knowledge of level of care criteria is required.

• Knowledge of state and federal regulations is desirable.Work is performed in general office environment, with some exposure to patient care areas when meeting with physicians, managers, etc. or to review other records not readily available.

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EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

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