SantaFeRecruiter
the smart solution for Santa Fe jobs

Clinical Appeals Nurse FT/40 HRS - Santa Fe

Company: Christus Health
Location: Santa Fe
Posted on: March 16, 2019

Job Description:

DescriptionResponsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility.

RequirementsEDUCATION: Graduate of an accredited School of Nursing with an Associate or Bachelor's degree (Preferred) in nursing.CERTIFICATION/LICENSES: Current RN Nursing licenseInterqual and/or MCG certification preferred. Case Management (CCM) or Managed Care certification preferredSKILLS:Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-taskIntensive writing capabilities/efficienciesAbility to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff)Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomesAssertive and diplomatic communication, proven ability to function on a multidisciplinary teamExcellent organizational skills including effective time management, priority setting and process improvementAblility to apply InterQual and Milliman Care Guidelines (MCG) medical necessity criteria to a case as applicableUnderstanding of Medicare, Medicaid and third party reimbursement methodologiesEthics and Values -- Adheres to an appropriate (for the setting) and effective set of core values and beliefs during both good and bad times; acts in line with those values; rewards the right values and disapproves of others; practices what he/she preachesCreativity -- Comes up with a lot of new and unique ideas; easily makes connections among previously unrelated notions; tends to be seen as original and value-added in brainstorming settingsCustomer Focus -- Is dedicated to meeting the expectations and requirements of internal and external customers; gets first hand customer information and uses it for improvements in products and services; acts with the customers in mind; established and maintains effective relationships with customers and garnishes their trust and respect.Decision Quality -- Makes good decisions (without considering how much time it takes) based upon a mixture of analysis, wisdom, experience, and judgment; most of his/her solutions and suggestions turn out to be correct and accurate when judged over time; sought out by others for advice and solutions.Drive for Results -- Can be counted on to exceed goals successfully; is constantly and consistently one of the top performers; very bottom-line orientated; steadfastly pushes self and others for results.Peer Relationships -- Can quickly find common ground and solve problems for the good of all; can represent his/her own interests and yet be fair to other groups; can solve problems with peers with a minimum of noise; is seen as a team player and is cooperative; easily gains trust and support of peers; encourages collaboration; can be candid with peers.Priority Setting -- Spends his/her time and the time of others on what's important; quickly zeros in on the critical few and puts the trivial many aside; can quickly sense what will help or hinder accomplishing a goal; eliminates roadblocks; creates focus.EXPERIENCE: Two to four years of Case Management experience. Two to three years' experience in the denial and appeal process. Experience with managed care, governmental and/or RAC appeals strongly preferred. Computer experience in Microsoft Office (Word and Excel).NATURE OF SUPERVISION:-Responsible to: Director of Case ManagementENVIRONMENT:-Bloodborne pathogen: AWorks in a clean, well-lighted, ventilated smoke-free environment.PHYSICAL REQUIREMENTS: Vision acuity at least 20/40; hearing acuity at least conversational; color perception. Lift/Carry objects more than 40 lbs. per day.

Keywords: Christus Health, Santa Fe , Clinical Appeals Nurse FT/40 HRS - Santa Fe, Healthcare , Santa Fe, New Mexico

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Healthcare Jobs


Travel RN - Med/Surg - Nights - Albuquerque , NM
Description: FlexCare is a nationwide leader in the staffing of travel nurses and clinicians. With access to thousands
Company: FlexCare Medical Staffing
Location: Albuquerque
Posted on: 03/19/2019

Physician: Hospitalist Needed for LTAH in Albuquerque, NM - JOB-
Description: A long term acute care hospital in Albuquerque, New Mexico needs additional hospitalist support. Your schedule options are flexible- there are multiple options for 10-hour shifts daily. You will be supported (more...)
Company: CompHealth
Location: Albuquerque
Posted on: 03/19/2019

Pediatrician (Physician #)
Description: br No visas. BE/BC Pediatrician to join the hospital' s active medical staff. Over 1000 babies annually. br ul li Office space and staff ready for you to see your first patient li Experience (more...)
Company: Spot On Recruiting, Inc.
Location: Albuquerque
Posted on: 03/19/2019


Primary Care Nurse Pracititoner Job in Albuquerque, NM (RN #)
Description: Family Practice/Primary Care opening in Albuquerque, New Mexico. Nurse Practitioner Are you ready to explore new places while building your resume At AB Staffing, we specialize in placing healthcare (more...)
Company: AB Staffing Solutions, LLC
Location: Albuquerque
Posted on: 03/19/2019

Certified Nursing Assistant (Full Time)
Description: Genesis is one of the nation's leading providers of post-acute healthcare services from short-term to long-term care and a wide variety of living options and professional clinical services.
Company: Ladera Center - Genesis HealthCare
Location: Albuquerque
Posted on: 03/19/2019

Hospitalist in NM - Hospitalist Needed for LTAH in Albuquerque, NM
Description: Hospitalist opening in Albuquerque, New Mexico. This and other physician jobs brought to you by DocCafe.com A long term acute care hospital in Albuquerque, New Mexico needs additional hospitalist support. (more...)
Company: CompHealth
Location: Albuquerque
Posted on: 03/19/2019

Critical Care Nurse
Description: Position SummaryYou earned the degree, now get the respect. Nurses are vital to quality patient care, and in the Air Force, they're treated that way. Our nurses are respected members of a team of highly (more...)
Company: U.S. Air Force
Location: Albuquerque
Posted on: 03/19/2019

Certified Nursing Assistant (Full Time)
Description: Genesis is one of the nation's leading providers of post-acute healthcare services from short-term to long-term care and a wide variety of living options and professional clinical services.
Company: Las Palomas Center Genesis HealthCare
Location: Albuquerque
Posted on: 03/19/2019

Physician: Neurohospitalist to Work a Block Schedule in Metr
Description: Employer is working with a multi-specialty group in Albuquerque, NM with their search for a Neurologist. Their need is for a Neurohospitalist who enjoys and is comfortable with stroke. You will work a (more...)
Company: CompHealth
Location: Albuquerque
Posted on: 03/19/2019

Travel RN-Dialysis Nurse - Chronic Travel Dialysis Nurse is
Description: A Chronic dialysis program in the beautiful state of New Mexico is in need of an experienced dialysis nurse. Applicants should have a NM/Compact License and at least one year of dialysis experience for (more...)
Company: Foundation Medical Staffing
Location: Albuquerque
Posted on: 03/19/2019

Log In or Create An Account

Get the latest New Mexico jobs by following @recnetNM on Twitter!

Santa Fe RSS job feeds