RN UM Denials & Appeals

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives. Work Shift Day (United States of America) Job Summary: The Clinical Appeals Process focuses on the review and analysis of medical necessity and authorization payer denials rationales and provides appropriate medical necessity appeal services. The Appeals Nurse will review all denial rationales and case-specific medical records for compliance, accuracy and completeness in accordance with departmental policies and regulations, medical necessity criteria set, payer regulations and other contractual requirements. The appeal nurse will work in conjunction with the UM medical director in constructing appeal letters as appropriate. Job Requirements: Review payer denial response letters in comparison to medical records Prioritize denials based on expiration dates and dollar amount Communicate with all responsible parties regarding missing or insufficient medical documentation Make referrals to Medical Director for physician level reviews Review medical documentation for adherence to Medicare and other payer guidelines relating to inpatient or outpatient services and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided Document UM team involvement and appeal process in star and UM denial module Collect data on trends and communicate to the appropriate hospital departments including the manage care team for JOC engagement. Partner with other hospital/health system team members to eliminate unfavorable trends Work with department manager to orient an onboard new team members Perform other related duties as required Core Responsibilities and Essential Functions: Review payer denial response letters in comparison to medical records * Prioritize denials based on expiration dates and dollar amount * Communicate with all responsible parties regarding missing or insufficient medical documentation * Make referrals to Medical Director for physician level reviews * Review medical documentation for adherence to Medicare and other payer guidelines relating to inpatient or outpatient services and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided * Document UM team involvement and appeal process in star and UM denial module * Collect data on trends and communicate to the appropriate hospital departments including the manage care team for JOC engagement. Partner with other hospital/health system team members to eliminate unfavorable trends, * Perform other related duties as required * Work with department manager to orient an onboard new team members Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct. Required Minimum Education: At least a 2 year degree in nursing Required and Bachelor's Degree or above Preferred Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated. Reg Nurse (Single State) or RN - Multi-state Compact Additional License(s) and Certification(s): Required Minimum Experience: Minimum 3 years experience as a case manager, discharge planner, utilization review nurse Required and Minimum 3 years experience as a staff nurse in an acute care setting Required Required Minimum Skills: Proficient in typing Experience with Microsoft Office suite Ability to learn and understand various clinical software applications Strong clinical judgment and multitasking ability Excellent problem-solving skills Self-motivation and ability of working independently with limited supervision and structure Excellent interpersonal, verbal, and written communication skills Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more. Nationally ranked and locally recognized for our high-quality care and inclusive culture, Wellstar is one of Georgia’s largest and most integrated healthcare systems. Every day, 24,000 of us work together to provide personalized care for patients at every age and stage of life – and our team members are the foundation of that care. Mission, Vision & Values At a time when the healthcare industry is changing rapidly, Wellstar remains committed to exceeding patients’ and team members’ expectations, while transforming healthcare delivery. OUR MISSION: To enhance the health and well-being of every person we serve. OUR VISION: Deliver world-class healthcare to every person, every time. OUR VALUES: We serve with compassion We pursue excellence We honor every voice Culture of Excellence Wellstar consistently receives attention and accolades from national organizations that set the standards for world-class care. Our system-wide practice of safety principles, assessing and addressing errors and seeking feedback from our patients and customers continually earns recognition for advances in safety and quality. Featured on the FORTUNE “100 Best Companies to Work For” list and Seramount 100 Best Companies list, we not only provide top-notch care for our patients, but also foster the culture of Wellstar as a Great Place to Work.