CLINICAL APPEALS NURSE- ORANGE COUNTY, CA

Currently, Tenet's Patient Financial Services organization is seeking a Clinical Appeals Nurse for the Alhambra Business Office located in Alhambra, CA.

Performs retrospective medical necessity reviews using InterQual Criteria and clinical nursing judgment to determine appeals after denials have occurred.

Review Worker's Compensation claims, and make recommendations from clinical findings/results of Showcase Queries, and draft appeal letters according to policy and procedure.

Review all existing documentation such as: UB, IB, EOB, and Managed Care. Contract to verify claim balance calculation and ensure integrity in documentation. Documents accounts indicating action taken on account in FUS, ACE, and eDM as appropriate.

Provides feedback based on issues identified when reviewing accounts for appeal potential whether it be facility, case management, payor, or HIM issues, to initiate process improvement. Represents RBO at any mediation hearings related to Worker's Compensation claims.

Mails appeal letters, maintains appeal spreadsheets and filing system, eDM data entry, and receives incoming correspondence.
REQUIREMENTS
Licensure: Current, valid state RN or LPN license. Understanding of business service functions including billing, collections, insurance and appeals.

Personal computer knowledge including Microsoft Office, Word and Excel.

Working Knowledge of InterQual Criteria, LMRP's, both Mutual and State, Medicare Coverage Guidelines.

Working Knowledge of Managed Care, Worker's Compensation, and Medicare payment methodology.