About Professional Technical Jobs
By being hired into one of our Professional\Technical jobs at EvergreenHealth, you’ll be a key member of the EvergreenHealth team. Individuals in Professional\Technical careers come from a variety of backgrounds, bringing an assortment of knowledge and skills to every area of our business. Please click on your desired Professional\Technical job below to learn more about the exact qualifications. An opportunity at EvergreenHealth may be waiting for you!
Clinical Appeals Specialist
RN Position - Care Management - Flexible shifts and hours available, 32-40 hours per week
Responsible for the review and resolution of clinical claim denials and audit determinations. Utilizes clinical expertise to interpret documentation and write appeals that utilize nationally recognized criteria to support the medical necessity of services billed. Understands and references Medicare and commercial payer policies to support appeal rationales. Communicates and coordinates effectively with all levels of the organization and payer representatives. Analyzes trends and collaborates with internal and external partners to identify opportunities to reduce denials by improving processes.
License, Certification, Education or Experience:
REQUIRED for the position:
1. Licensed as a Registered Nurse (RN) in the State of Washington.
2. Experience in a clinical, health insurance, coding/claims review or case management setting.
3. Strong written and verbal communication skills.
4. Must be highly detail oriented.
5. Must have superior organizational skills.
6. Ability to understand and interpret regulatory guidance, contract language and payer specific policies.
7. Ability to make decisions with respect to his/her delegated responsibilities.
DESIRED for the position:
1. Bachelor’s degree in a healthcare or related area.
2. 3 years of clinical nursing and/or case management experience
3. Knowledge of Milliman (MCG), Interqual or other admission guideline tools.
4. Proficient knowledge of diagnosis coding and sequencing guidelines.
5. Proficiency in Cerner electronic medical record.
6. General knowledge of healthcare revenue cycle including familiarity with reimbursement methodology, charge capture and billing processes.