Job Description

THE POSITION:
The Clinical Appeals Nurse is responsible for managing medical denials by conducting a comprehensive review of clinical documentation to determine if medical necessity criteria are met. Where an appeal is warranted, the Clinical Appeals Nurse consults with healthcare providers, patients and the medical record to compose sound, compelling, factual arguments for submission. They manage the appeals process within prescribed timeframes in order to meet the operational goals of the department. Attendance at Administrative Law Judge Hearings may be required.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
Our employees are tasked with delivering excellent business results. These results are achieved by:

• Successfully managing the appeals process from beginning to end within the designated timeframe
• Ensuring appropriate communication through the process with patient, insurance company and internal business partners
• Ensuring compliance with HIPAA regulations, to include confidentiality, as required
• All other duties as assigned

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.

EXPECT AT IONS OF THE JOB:

• Determine why cases are denied and if an appeal is warranted using knowledge of payer requirements with medical chart data
• Utilize pre-existing criteria, clinical evidence and other resources as needed to develop sound and well-supported appeal arguments
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies
• Request additional information from providers, as appropriate, to facilitate timely appeals
• Gather and prepare case information for participation in Administrative Law hearings
• Summarize and present appeal outcomes to clients and participate in client meetings as needed
• Reviewing documentation related and level of care decisions with clients

The above list reflects the general details necessary to describe the expectations of the position and shall not be construed as the only expectations that may be assigned for the position.

An individual in this position must be able to successfully perform the expectations listed above.

Qualifications

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES:

The requirements listed below are representative of the experience, education, knowledge, skill and/or abilities required.

• Bachelor’s Degree in Nursing
• Current MO RN license in good standing
• 4 years’ experience as a clinical nurse in an acute care setting
• Knowledge of third-party payer regulations related to utilization and quality review
• Analytical, creative, and interpersonal skills essential
• Excellent communication (written, verbal, and presentation) skills
• Strong clinical and regulatory knowledge and skills as well as knowledge of payer requirements
• Strong organizational skills
• Demonstrated sense of urgency to drive to successful outcomes within the minimum required time frames

PREFERRED QUALIFICATIONS:

• 2 years’ experience in case management, discharge planning, and/or utilization review
• Experience with infusion and home health services as well as managed care
• Experience working with patient consumers with rare chronic disorders
• Exhibits an upbeat attitude, a genuine interest in others and a sense of humor. Energizes others and heightens morale through her/his attitude
• Commitment to teamwork
• Creates a climate that motivates and encourages others to participate
• Transforms creative ideas into original solutions that positively impact the company’s performance
• Proves to be a professional of unquestionable integrity, credibility and character who demonstrates high moral and ethical behavior

PHYSICAL/MENTAL DEMANDS AND WORKING ENVIRONMENT:

The physical and mental requirements along with the work environment characteristics described here are representative of those an individual encounters while performing the essential functions of this position.

This is a largely sedentary role. While performing the essential functions of this job the employee is regularly required to stand and/or sit for long period of time (up to 90%). Additionally they are regularly required to talk or hear, type and engage in repetitive motion, reach and grasp; occasionally required to lift and/or move up to 25 pounds. The employee is intermittently required to stoop or crouch; push or pull; or kneel. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

This role requires mental alertness. The employee must regularly communicate both verbally and written; concentrate on tasks; and remember and observe details. The employee must frequently adjust to changes; handle stress and emotions; and think analytically.

This job operates in a professional office environment. This role routinely uses standard office equipment.

The noise level in the work environment is usually moderate, with frequent interruptions and multiple demands.

Additional Information

OUR CULTURAL BELIEFS:

Patient Minded I act with the patient’s best interest in mind.

Client Delight I own every client experience and its impact on results.

Take Action I am empowered and empower others to act now.

Grow Talent I own my development and invest in the development of others.

Win Together I passionately connect with anyone, anywhere, anytime to achieve results.

Communication Matters I speak up to create transparent, thoughtful and timely dialogue.

Embrace Diversity I create an environment of awareness and respect.

Always Innovate I am bold and creative in everything I do.

EVERSANA is committed to providing competitive salaries and benefits for all employees. The anticipated base salary range for this position is $67,500 to $94,000 and is not applicable to locations outside of the U.S. The base salary range represents the low and high end of the salary range for this position. Compensation will be determined based on relevant experience, other job-related qualifications/skills, and geographic location (to account for comparative cost of living). EVERSANA reserves the right to modify this base salary range at any time.

Our team is aware of recent fraudulent job offers in the market, misrepresenting EVERSANA. Recruitment fraud is a sophisticated scam commonly perpetrated through online services using fake websites, unsolicited e-mails, or even text messages claiming to be a legitimate company. Some of these scams request personal information and even payment for training or job application fees. Please know EVERSANA would never require personal information nor payment of any kind during the employment process. We respect the personal rights of all candidates looking to explore careers at EVERSANA.

From EVERSANA’s inception, Diversity, Equity & Inclusion have always been key to our success. We are an Equal Opportunity Employer, and our employees are people with different strengths, experiences, and backgrounds who share a passion for improving the lives of patients and leading innovation within the healthcare industry. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion, and many other parts of one’s identity. All of our employees’ points of view are key to our success, and inclusion is everyone's responsibility.

Consistent with the Americans with Disabilities Act (ADA) and applicable state and local laws, it is the policy of EVERSANA to provide reasonable accommodation when requested by a qualified applicant or candidate with a disability, unless such accommodation would cause an undue hardship for EVERSANA. The policy regarding requests for reasonable accommodations applies to all aspects of the hiring process. If reasonable accommodation is needed to participate in the interview and hiring process, please contact us at applicantsupport@eversana.com.

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