RN - Appeals/Utilization Review
Job Summary Responsible for the facilitation and management of medical appeals and may assist with clinically oriented claims issues. Investigates and resolves member and practitioner appeals within plan, regulatory and accreditation timeframes. Performs ER review activities. Minimum Qualifications Education/Training Associates degree in nursing from an Accredited Nursing Program. Bachelors Degree in Nursing preferred. Experience 5 years of diverse clinical experience; 2 years of recent utilization review experience. Prior experience in appeals preferred. Experience applying industry standard criteria to clinical information, for example, InterQual. Knowledge of common and standard authorization processes. License/Certification/Registration Active and Unrestricted Nursing License in the State of Maryland or the District of Columbia with a willingness to obtain license in both jurisdictions. No prior, current or pending Medicare or Medicaid sanctions. No RN license sanctions. Knowledge, Skills & Abilities Ability to read and interpret medical records. Ability to abstract, analyze and summarize medical/clinical situations. Excellent verbal and written communication skills. Ability to work independently. Ability to prioritize and organize work to meet deadlines. Knowledge of medical claims and coding desirable. Ability to work effectively in teams. Computer/Keyboarding skills and familiarity with Microsoft Office or similar software. Maintain current knowledge of MFC policies and procedures and participate in continuing education activities, as appropriate. Primary Duties and Responsibilities Abstracts medical record, analyzes clinical information and Approves payment of services in accordance with NCQA, Maryland COMAR, the District of Columbia contract and Employer Policies/Procedures. Conducts an initial medical record review for all clinical appeals including inpatient and outpatient and prepare a summary of the case outlining the issue(s) for the Physician Advisors review. Appeals Nurse prepares a draft response to the appeal for review by the Physician Advisor in accordance with NCQA, Maryland COMAR, the District of Columbia contract and Employer Policies/Procedures. Conducts an initial review of appeals of emergency room administrative denials against Prudent Layperson Criteria, medical necessity, appropriateness of coding, and health plan policies. Appeals Nurse overturns administrative denials and approves payment when standards are met. Conducts an initial review of appeals of emergency room non-administrative denials against Prudent Layperson Criteria, medical necessity, appropriateness of coding, and health plan policies. Appeals Nurse makes a recommendation to uphold or overturn the denial and prepares a draft response for review by the Physician Advisor in accordance with NCQA, Maryland COMAR, the District of Columbia contract and Employer Policies/Procedures. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Ensures compliance with hospital /facility policies and procedures and governmental/accreditation regulations. Coordinates closely with Physician Advisors on handling denials, adverse determinations, or clinically oriented grievances. Documents all appeals in an accurate and timely manner per policy, related follow-up activities and final outcomes in clinical software system while concurrently maintaining secure, comprehensive and clearly defined files. Documents ER review activity in the clinical software system. Documents in the clinical software system, as appropriate. Reviews each appeal received to determine whether the case is a medical appeal or a claim/administrative appeal. Forwards recommendation to Deny services to Physician Advisor. Appeals Nurse will prepare draft of denial reason for PA review in accordance with NCQA, Maryland COMAR, the District of Columbia contract and Employer Policies/Procedures. Participates in inter rater reviews and associated meetings/activities. Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate. Participates in the processing of ER records for appropriateness of service. Performs other duties as assigned. Performs primary preparation of ER Claims in the clinical software system to administratively deny claims without attached medical records and duplicate submissions. Works collaboratively with the Appeals staff, Administrative staff and Physician Advisors. About MedStar Health MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, DC, region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.