Clinical Appeals Nurse - Clinical
Company: Halifax Health
Location: Daytona Beach
Posted on: May 16, 2022
Clinical Appeals NurseOverview
Halifax Health is seeking a Clinical Appeals Nurse.
The Clinical Appeals Nurse will play an active role in the Revenue
Cycle by successfully performing the tracking, resolution, and
collection of Clinical Denials and Appeals. The Clinical Appeals
Nurse will accurately document into the host system and QMS and
supply the Manager of Case Management with accurate work stats.
This person will also actively participate in Quality Improvement
and process flows.
* Active Florida RN license, or bachelor degree in related health
field or equivalent experience.
* Prefer 3-5 years of Case Management, Utilization Review, or
hospital business experience in the area of reimbursement
* Must possess analytical skills.
* Prefer some experience in dealing with insurance carriers on
disputes and settlement of claims.
* Must have knowledge of :
* EQ Health/Medicaid rules and regulations;
* FMQAI, PEPP;
* Cobra and Emtala rules and regulations;
* InterQual and Millimen Criteria for utilization review.
* Must have an understanding of the billing and collection process
as related to healthcare claims.
* Must be able to deal effectively with the public and
* Must formulate comprehensive letters and account notes.
* Must have good PC knowledge and skills.
* Must be able to work successfully in a "team-work"
Job Duties and Responsibilities
* Identify clinical denials via fax, correspondence, system
worklists, email, hard copy remittance advice and any other data
* Record clinical denials in the denial tracking database.
* Request all materials needed to submit a timely appeal.
* Send the appeal in accordance with specific payor guidelines.
* Record clinical appeals in the denial tracking database.
* Run follow up reports for aggressive follow up, as per
* Record final outcomes in the denial tracking database.
* Participate in quality improvement for various stages of the
* Provide clinical denial statistics to Manager, Case Management
and Administration as needed.
* Provide clinical expertise and decision making to non clinical
staff as needed.
* Able to analyze and monitor financial data reports.
Recognized by The Joint Commission as a Top Performer on Key
Quality Measures, Halifax Health serves Volusia and Flagler
counties, providing a continuum of healthcare services through a
network of organizations including a tertiary hospital, community
hospital, psychiatric services, a cancer treatment center with four
outreach locations, the area's largest hospice, a center for
inpatient rehabilitation, primary care walk-in clinics, a walk-in
clinic specializing in women's health, two community clinics, three
children's medical practices, a home healthcare agency, and an
exclusive provider organization. Halifax Health offers the area's
only Level II Trauma Center, Comprehensive Stroke Center, Pediatric
Intensive Care Unit, Pediatric Emergency Department, Child and
Adolescent Behavioral Services, complete Neurosurgical Services, OB
Emergency Department and Level II Neonatal Intensive Care Unit that
cares for babies born as early as 28 weeks. For more information,
Keywords: Halifax Health, Daytona Beach , Clinical Appeals Nurse - Clinical, Healthcare , Daytona Beach, Florida
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