Confluence Health
Salary Range $39.33 - $61.57
Overview Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members.
Employees of Confluence Health receive a wide range of benefits in addition to compensation.
Medical, Dental & Vision Insurance
Flexible Spending Accounts & Health Saving Accounts
CH Wellness Program
Paid Time Off
Generous Retirement Plans
Life Insurance
Long-Term Disability
Gym Membership Discount
Tuition Reimbursement
Employee Assistance Program
Adoption Assistance
Shift Differential
For more information on our Benefits & Perks, click here!
Summary The Clinical Appeals RN will review and analyze denied and/or downgraded claims received from commercial, private and state payers. This role will utilize nursing and coding expertise to determine whether the claim should be appealed. For all applicable claims the RN will construct a compelling appeal letter based upon current coding guidelines, medical necessity of services rendered, as well as track and trend denial root causes.
Position Reports To:
Revenue Integrity Director
Essential Functions
Serves as the liaison with government and commercial payers to resolved complex claims, ensure favorable reimbursement, and address other billing or payment issues.
Ability to write articulate and concise appeals by applying clinical knowledge, coding expertise and medical necessity.
Ability to detect trends resulting in denials and constructively report on the root cause to assist in resolution and prevention.
Responsible for evaluating likelihood of receiving a favorable resolution of medical necessity denials, payment discrepancies and contract misinterpretations.
Responsible for clearly documenting actions taken in each patient account.
Collaborates with physicians and interdisciplinary team as appropriate.
Complies with the various payer rules regarding the appeal/denials process.
Communicates with the patient access and billing teams as needed to facilitate appropriate actions for recoupment of denied/downgraded claims.
Manages assigned workload of accounts so that appeals are submitted timely in accordance with payer timeframes.
Performs other duties as assigned.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
Qualifications Required:
Three (3) years of acute care experience or equivalent expertise and two (2) years' experience in utilization review.
Proficient with Microsoft Office suite, internet and other systems (CMS, Government & commercial payor portals etc.).
Analytical aptitude with the ability to collect, analyze and present data effectively.
Must be a team-player and maintain a positive, resourceful attitude toward achieving the overall departmental and organizational goals.
Strong attention to detail with excellent communication skills in both written and verbal forms.
Ability to work independently and with limited supervision.
Ability to communicate changes effectively, build commitment, and overcome resistance.
Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499).
Desired:
Bachelor's Degree.
2+ years experience working in the Epic system.
Certified Coding Specialist (CCS).
Physical/Sensory Demands O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday.
F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday.
C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday.
Physical/Sensory Demands ForThis Position
Walking - C
Sitting/Standing - C
Reaching: Shoulder Height - O
Reaching: Above shoulder height - O
Reaching: Below shoulder height - O
Climbing - O
Pulling/Pushing: 25 pounds or less - O
Pulling/Pushing: 25 pounds to 50 pounds - O
Pulling/Pushing: Over 50 pounds - O
Lifting: 25 pounds or less - F
Lifting: 25 pounds to 50 pounds - O
Lifting: Over 50 pounds - O
Carrying: 25 pounds or less - F
Carrying: 25 pounds to 50 pounds - O
Carrying: Over 50 pounds - O
Crawling/Kneeling - O
Bending/Stooping/Crouching - F
Twisting/Turning - O
Repetitive Movement - F
Working Conditions
Work is performed in a normal office environment. Requires a combination of working independently and also working closely with others. Hours may be irregular at times. May require travel to other CWH & C, WVH & C and CH locations. Requires building relationships and frequent contact with other departments throughout the organization.
Job Classification
FLSA:
Exempt
Hourly/Salary:
Salary
Physical Exposures For This Position
Unprotected Heights - No
Heat - No
Cold - No
Mechanical Hazards - Yes
Hazardous Substances - Yes
Blood Borne Pathogens Exposure Potential - Yes
Lighting - No
Noise - No
Ionizing/Non-Ionizing Radiation - No
Infectious Diseases - Yes
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Overview Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members.
Employees of Confluence Health receive a wide range of benefits in addition to compensation.
Medical, Dental & Vision Insurance
Flexible Spending Accounts & Health Saving Accounts
CH Wellness Program
Paid Time Off
Generous Retirement Plans
Life Insurance
Long-Term Disability
Gym Membership Discount
Tuition Reimbursement
Employee Assistance Program
Adoption Assistance
Shift Differential
For more information on our Benefits & Perks, click here!
Summary The Clinical Appeals RN will review and analyze denied and/or downgraded claims received from commercial, private and state payers. This role will utilize nursing and coding expertise to determine whether the claim should be appealed. For all applicable claims the RN will construct a compelling appeal letter based upon current coding guidelines, medical necessity of services rendered, as well as track and trend denial root causes.
Position Reports To:
Revenue Integrity Director
Essential Functions
Serves as the liaison with government and commercial payers to resolved complex claims, ensure favorable reimbursement, and address other billing or payment issues.
Ability to write articulate and concise appeals by applying clinical knowledge, coding expertise and medical necessity.
Ability to detect trends resulting in denials and constructively report on the root cause to assist in resolution and prevention.
Responsible for evaluating likelihood of receiving a favorable resolution of medical necessity denials, payment discrepancies and contract misinterpretations.
Responsible for clearly documenting actions taken in each patient account.
Collaborates with physicians and interdisciplinary team as appropriate.
Complies with the various payer rules regarding the appeal/denials process.
Communicates with the patient access and billing teams as needed to facilitate appropriate actions for recoupment of denied/downgraded claims.
Manages assigned workload of accounts so that appeals are submitted timely in accordance with payer timeframes.
Performs other duties as assigned.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
Qualifications Required:
Three (3) years of acute care experience or equivalent expertise and two (2) years' experience in utilization review.
Proficient with Microsoft Office suite, internet and other systems (CMS, Government & commercial payor portals etc.).
Analytical aptitude with the ability to collect, analyze and present data effectively.
Must be a team-player and maintain a positive, resourceful attitude toward achieving the overall departmental and organizational goals.
Strong attention to detail with excellent communication skills in both written and verbal forms.
Ability to work independently and with limited supervision.
Ability to communicate changes effectively, build commitment, and overcome resistance.
Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499).
Desired:
Bachelor's Degree.
2+ years experience working in the Epic system.
Certified Coding Specialist (CCS).
Physical/Sensory Demands O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday.
F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday.
C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday.
Physical/Sensory Demands ForThis Position
Walking - C
Sitting/Standing - C
Reaching: Shoulder Height - O
Reaching: Above shoulder height - O
Reaching: Below shoulder height - O
Climbing - O
Pulling/Pushing: 25 pounds or less - O
Pulling/Pushing: 25 pounds to 50 pounds - O
Pulling/Pushing: Over 50 pounds - O
Lifting: 25 pounds or less - F
Lifting: 25 pounds to 50 pounds - O
Lifting: Over 50 pounds - O
Carrying: 25 pounds or less - F
Carrying: 25 pounds to 50 pounds - O
Carrying: Over 50 pounds - O
Crawling/Kneeling - O
Bending/Stooping/Crouching - F
Twisting/Turning - O
Repetitive Movement - F
Working Conditions
Work is performed in a normal office environment. Requires a combination of working independently and also working closely with others. Hours may be irregular at times. May require travel to other CWH & C, WVH & C and CH locations. Requires building relationships and frequent contact with other departments throughout the organization.
Job Classification
FLSA:
Exempt
Hourly/Salary:
Salary
Physical Exposures For This Position
Unprotected Heights - No
Heat - No
Cold - No
Mechanical Hazards - Yes
Hazardous Substances - Yes
Blood Borne Pathogens Exposure Potential - Yes
Lighting - No
Noise - No
Ionizing/Non-Ionizing Radiation - No
Infectious Diseases - Yes
#J-18808-Ljbffr