**Description** _Summary:_Responsible for the management and communication of denialsappeals receivedfrom third party payers, managed care companies, andor governmententitiesauditors related to medical necessity andor level of care. Thisassociate will be a liaison and point of contact for clinical denials andappeal inquiries. The Clinical Appeals Nurse will review each caseidentifiedreferred for appeal based on Milliman Care Guidelines (MCG),InterQual, andor other relevant guidelines, determined the viability of theappeal, and manage the appeal process. The Clinical Appeals Nurse isresponsible for appealing all inappropriate denials through all possiblelevels of the appeal process. The RN Clinical Appeals Nurse will activelymanage, maintain and communicate denialappeal activity to appropriatestakeholders, and report suspected or emerging trends related to payerdenials. Working with Case Management leadership, this individual willorchestrate education and other performance improvement initiatives to impactclinical quality, improve efficiency and mitigate lost revenue related tomedical necessity denials. Key Performance and trends related todenialsappeals will be reported to the facility._Responsibilities:_ * Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services * Review governmental contractors response letter in comparison to the medical records * Communicates with facility regarding missing or insufficient medical documentation * Review medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided * Research issues using federal or law, federal regulations, and relevant CMS policies Communicates with members of the healthcare team identifying root causes for potential denials * Communicates with the CMOVPMA regarding appeals and obtain signature for appeals * Assures all discussions and appeals are filed timely * Completes data entry in the Denial database for tracking, trends, and analysis_Requirements:_ * Associates Degree in Nursing * RN License in state of employment or compact**_Work Type:_**Full Time **EEO is the law - click below for more information:**We endeavor to make this site accessible to any and all users. If you wouldlike to contact us regarding the accessibility of our website or needassistance completing the application process, please contact us at (844)257-6925.