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APPEALS SPECIALIST

owensboroworkdaytest
Owensboro, Kentucky, United States, 42301
Full-time

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.

PI250822498

27 days ago
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