Lifespan
Overview
The Clinical Appeals Specialist reports to the Manager Appeals. Under general supervision and within Brown University Health policies and procedures, the specialist works collaboratively with The Miriam Hospital, Rhode Island Hospital, and multiple system-wide departments. Responsibilities include reviewing medical records to determine appeal information, developing appeal correspondence, analyzing clinical denials using InterQual criteria and CMS guidelines, and reporting audit data at the facility and system-wide levels. The role also involves providing education to Brown University Health staff and physicians to reduce future audit exposure.
Brown University Health employees are expected to role model the organization’s values of Compassion, Accountability, Respect, and Excellence. All employees are also expected to demonstrate the core Success Factors, which include: Instill Trust and Value Differences Patient and Community Focus and Collaborate
Responsibilities
Apply the corporate values of respect, honesty, and fairness while pursuing excellence in improving the health status of the region.
Adhere to the Brown University Health Corporate Compliance Program and Code of Conduct.
Coordinate governmental and third-party appeals with attending physicians and the medical director.
Collaborate with government oversight agencies and third-party payers regarding audits.
Prepare, review, develop, and maintain manual and computerized documentation and records of denials and appeal data.
Present high-level professional presentations.
Participate on hospital, state, and department committees to develop policies and procedures related to audits and appeals.
Engage in ongoing independent study and professional activities to maintain knowledge of payer regulations and reimbursement issues.
Research and identify improvement opportunities and submit recommendations to manager or director.
Conduct retrospective reviews and audits of hospital records to determine appropriate and adequately documented level of care.
Work collaboratively at all levels of the organization.
Lead or participate in various committees, task forces, and quality improvement teams as needed.
Perform other duties as assigned.
Work Locations / Expectations
Full-time schedule in office.
Full-time schedule in a dedicated home space.
Part-time schedule in office and in a dedicated home space.
Minimum Qualifications
Licensure as a Registered Nurse in the State of Rhode Island or a Registered Nurse under the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.
Current RN licensure in Rhode Island required; Bachelor’s Degree in Nursing, Health Science, or Health Business required; Master’s Degree preferred.
Three or more years of recent clinical and/or administrative experience in medical/surgical nursing; two years related to utilization review activities, demonstrating organizational skills and sound clinical judgment.
Working knowledge of level of care criteria required; knowledge of state and federal regulations desirable.
Work Environment and Physical Requirements General office environment with exposure to patient care areas when meeting with physicians, managers, or reviewing records not readily available.
Independent Action Performs independently within the department’s policies and procedures, referring specific complex problems to the supervisor when clarification is required.
Supervisory Responsibility None.
Pay Range: $78,748.80-$157,476.80
Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.
Location: 593 Eddy Street - Gerry House - N/A Providence, Rhode Island 02903
Work Type: M-F 8:00 AM - 4:30 PM
Work Shift: Day
Daily Hours: 8 hours
Driving Required: No
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Brown University Health employees are expected to role model the organization’s values of Compassion, Accountability, Respect, and Excellence. All employees are also expected to demonstrate the core Success Factors, which include: Instill Trust and Value Differences Patient and Community Focus and Collaborate
Responsibilities
Apply the corporate values of respect, honesty, and fairness while pursuing excellence in improving the health status of the region.
Adhere to the Brown University Health Corporate Compliance Program and Code of Conduct.
Coordinate governmental and third-party appeals with attending physicians and the medical director.
Collaborate with government oversight agencies and third-party payers regarding audits.
Prepare, review, develop, and maintain manual and computerized documentation and records of denials and appeal data.
Present high-level professional presentations.
Participate on hospital, state, and department committees to develop policies and procedures related to audits and appeals.
Engage in ongoing independent study and professional activities to maintain knowledge of payer regulations and reimbursement issues.
Research and identify improvement opportunities and submit recommendations to manager or director.
Conduct retrospective reviews and audits of hospital records to determine appropriate and adequately documented level of care.
Work collaboratively at all levels of the organization.
Lead or participate in various committees, task forces, and quality improvement teams as needed.
Perform other duties as assigned.
Work Locations / Expectations
Full-time schedule in office.
Full-time schedule in a dedicated home space.
Part-time schedule in office and in a dedicated home space.
Minimum Qualifications
Licensure as a Registered Nurse in the State of Rhode Island or a Registered Nurse under the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.
Current RN licensure in Rhode Island required; Bachelor’s Degree in Nursing, Health Science, or Health Business required; Master’s Degree preferred.
Three or more years of recent clinical and/or administrative experience in medical/surgical nursing; two years related to utilization review activities, demonstrating organizational skills and sound clinical judgment.
Working knowledge of level of care criteria required; knowledge of state and federal regulations desirable.
Work Environment and Physical Requirements General office environment with exposure to patient care areas when meeting with physicians, managers, or reviewing records not readily available.
Independent Action Performs independently within the department’s policies and procedures, referring specific complex problems to the supervisor when clarification is required.
Supervisory Responsibility None.
Pay Range: $78,748.80-$157,476.80
Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.
Location: 593 Eddy Street - Gerry House - N/A Providence, Rhode Island 02903
Work Type: M-F 8:00 AM - 4:30 PM
Work Shift: Day
Daily Hours: 8 hours
Driving Required: No
#J-18808-Ljbffr