Denials Management Appeals Nurse

The Denials Management Appeals Nurse is responsible for managing our medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Denials Management Appeals Nurse will utilize his/her clinical background to address the clinical denials. The Denial Management Appeals Nurse will write sound, compelling factual arguments for appealing denials. The Denials Management Appeals Nurse is responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as for filing compliant appeals in accordance with Third party and governmental contracts. Performs a review of assigned cases comparing the bill to the medical record. Performs a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process. Reviews documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur Review findings with the hospital representatives and obtains an agreement on the discrepancies. Follows up on appeals in a timely fashion to ensure that cases are completed and informs supervisor of any changes, problems, or concerns that arise at a facility.