APPEALS SPECIALIST

Job Summary

Responsible for denial management on all governmental and commercial payers, including inpatient and outpatient claims. Job Responsibilities

• Conducts chart audits to determine most appropriate course of action when payer denial received.
• Composes credible appeal letters, utilizing : Federal and State regulations; Center for Medicare and Medicaid (CMS) Guidelines and policies;
• Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS) payment; ICD-10M Official Guidelines for Coding and Reporting;
• AHA Coding Clinics; InterQual Medical Necessity criteria; Current Procedural Terminology (CPT) Guidelines; Medical Standards of practice;

and published articles, journals and clinical studies.

• Collaborates extensively with Business Office / HIM / Auditing / Finance / Medical Director of Case Management / and others as appropriate in order to obtain resolution of denial.
• Effectively researches each case in search of data necessary to decide if case warrants appeal.
• Identifies and reports trends and issues to stakeholders.
• Examines the reason for denial and looks for inconsistencies inside of the option.
• Maintains up-to-date knowledge of CMS regulations and appeal rights.
• Enters accurate data related to the appeal process into system databases.

Qualifications

• Associate's degree or higher or Diploma in Nursing required upon hire AND
• Bachelor's degree or higher in Nursing required within 5 years of employment in this position
• A minimum of 2 years' relevant experience required
• RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire

Skills and Attributes

• Requires critical thinking skills and decisive judgment.
• Works under minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.

Physical Demands

• Standing : Occasionally
• Walking : Occasionally
• Sitting : Frequently
• Lifting 0-25 lbs : Rarely
• Lifting 25-75 lbs : Never
• Lifting over 75 lbs : Never
• Carrying 0-25 lbs : Rarely
• Carrying 25-75 lbs : Never
• Carrying over 75 lbs : Never
• Pushing / Pulling 0-25 lbs : Rarely
• Pushing / Pulling 25-75 lbs : Never
• Pushing / Pulling over 75 lbs : Never
• Climbing : Rarely
• Bending / Stooping : Rarely
• Kneeling : Rarely
• Crouching / Crawling : Rarely
• Reaching : Occasionally
• Talking : Frequently
• Hearing : Occasionally
• Repetitive Foot / Leg Movements : Never
• Repetitive Hand / Arm Movements : Frequently
• Keyboard Data Entry : Frequently
• Running : Never
• Vision : Depth Perception : Frequently
• Vision : Distinguish Color : Frequently
• Vision : Seeing Far : Frequently
• Vision : Seeing Near : Frequently

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.

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