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Clinical Appeals Nurse

Company: Halifax Hospital Medical Center
Location: Daytona Beach
Posted on: July 30, 2022

Job Description:

Halifax Healthis seeking aClinical AppealsNurse.

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 willaccurately document into the host system and QMS andsupply the Manager ofCase Management with accurate work stats. This person will alsoactively participate in Quality Improvement and process flows.

Job Qualifications:
Active FloridaRN license, or bachelor degree in related health field or equivalent experience.Prefer 3-5years of Case Management, Utilization Review, or hospital business experience in the area of reimbursement methodologies.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 physicians.Must formulate comprehensive letters and account notes.Must have good PC knowledge and skills.Must be able to work successfully in a "team-work" environment.

Job Duties and Responsibilities:
Identify clinical denials via fax, correspondence, system worklists, email, hard copy remittance advice and any other data source. 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 policy. Record final outcomes in the denial tracking database. Participate in quality improvement for various stages of the Revenue Cycle.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.

About Us:
Recognized as one of the 50 Top Cardiovascular Hospitals in the United States by IBM Watson Health, Halifax Health serves Volusia and Flagler counties, providing a continuum of health care services through a network of organizations including a tertiary hospital, two community hospitals, urgent care clinics, psychiatric services, a cancer treatment center with five outreach locations, the areas largest hospice, a center for inpatient rehabilitation, outpatient rehabilitation clinics, primary care walk-in clinics, a clinic specializing in womens health, a pediatric care community clinic, five pediatric medical practices, a home health care agency and an exclusive provider organization. Halifax Health offers the areas only Level II Trauma Center, Thrombectomy-Capable Stroke Center (TSC), Center for Transplant Services, Pediatric Intensive Care Unit, Child and Adolescent Behavioral Services, complete Neurosurgical Services, OB Emergency Department and Level III Neonatal Intensive Care Unit that cares for babies born earlier than 28 weeks. For more information, visit

Keywords: Halifax Hospital Medical Center, Daytona Beach , Clinical Appeals Nurse, Healthcare , Daytona Beach, Florida

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