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Appeals Nurse

Company: Community Health System
Location: Tucson
Posted on: November 23, 2021

Job Description:

Job Description Performs patient chart audits, including insurance defense audits, patient request, new program, special focus audits, and others. ESSENTIAL JOB FUNCTIONS: * Research medical records and compose clinically based, medical necessity appeals to overturn payer denials * Follow up on appeals for determinations and additional actions/resolution * Collects, aggregates, displays and conducts analysis of data obtained from monitoring and evaluating the quality of patient care via patient record review. * Investigates and responds to requests for additional information or payment denials from third-party payers. * Communicates observations, facts, and comments in an effective manner to the appropriate individual, department or her supervisor. * Demonstrates accurate knowledge of relevant laws policies, regulations and standards affecting decisions and interpretations. * Audits charges on accounts with medical records documentation to assure accuracy. If discrepancies (over or under) are found, charge corrections are made. Results of audits are communicated and action plans requested and followed-up on in a timely manner. Lack of response is communicated to the next level to ensure continuous operations improvement. * Maintains recordkeeping of audit statistics, for all aspects of audit work. Prepares summaries and trends of statistical data for management purposes. Disperses statistical data at given intervals to assist management with decision-making. Tracks audit requests and prepares a monthly summary, part of recordkeeping. * Coordinates external audits and works with external auditors to resolve discrepancies. * Provides assistance to patient inquiries regarding charge item questions, either by phone or written communication. * Demonstrates proficiency at hospital wide and/or department specific computer software and technology. EDUCATION, SKILLS & EXPERIENCE: * Education: Associates Degree * License: RN License -Required * Experience: * Three (3) years hospital nursing experience, prefer additional experience in case management or quality assurance. * Excellent human relations and oral/written communications skills required. * Machine Skills: Personal Computer, calculator, fax, personal computer and photocopier.

Keywords: Community Health System, Tucson , Appeals Nurse, Healthcare , Tucson, Arizona

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