We are Hiring AR Clinical Appeals Nurses at Peace Hospital!

Location: 2020 Newburg Rd Louisville KY

Shift: Fulltime, First Shift

About Us

Peace Hospital, part of UofL Health, is a private, non-profit behavioral health hospital. One of the largest behavioral health facilities in the nation, Peace Hospital is known for providing care for children, adolescents, adults and senior adults, age 55 and older. Our Kosair for Kids Children’s Peace Center is the largest and most comprehensive private provider of youth inpatient behavioral health services in the country treating children and adolescents with behavioral health and co-occurring disorders. We have a partial hospitalization program for school-aged children and an inpatient specialty program for children and adolescents who have complex treatment needs, such as intellectual or developmental disabilities accompanied by acute behavioral and psychiatric symptoms. UofL Health is home to over 14,000 team members, 1000+ providers, 200+ practice locations, 9 hospitals, and 4 medical centers.

Our Mission

As an academic health care system, we will transform the health of the communities we serve through compassionate, innovative, patient-centered care.

Job Summary:

The Clinical Appeals Nurse plays an integral role in the recovery of denied reimbursement for hospital services rendered to a patient by providing a comprehensive review of a members’ clinical information and comprising a verbal or written response depicting why the services were medically necessary. This position will be responsible for claim denials as well as pre or post-payment audits from insurance carriers or designated third part vendors. Responsible for the identification, mitigation, and prevention of clinical denials including medical necessity and authorization issues.

This position will maintain reporting and collaborate with the Payor Relations and Contracting Department during contract negotiations and settlements on denial issues and payment variances impacting payment from third party payers for consideration.

• Ensures clinical interventions are appropriate for the admitting diagnosis and reflects the standard of care as defined by the medical staff and health system.
• Utilizes clinical knowledge and defined standards of care to proactively identify inappropriate admit status based on identified criteria (MCG and Interqual Criteria).
• Communicates with physicians and multidisciplinary health system team members to effectively utilize all available resources to ensure a strong and efficient appeal is submitted.
• Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to the billed charges.
• Research commercial and governmental payor policies, regulations, and clinical abstracts related to claims payment to evaluate and appeal denied claims.
• Understanding of patient accounting documents – UB04, EOB
• Perform retrospective authorization requests for services already performed as needed.
• Supports billing staff by reviewing accounts as requested before claim submission to prevent clinical denials.
• Supports global denial prevention and mitigation efforts throughout the health system by attending denial prevention meetings and/or payer representative meetings.

Benefits & Perks

• Competitive Pay & Benefits Options
• Paid Vacation, Sick days, and Holidays
• Free tuition to UofL for Part- and Full-time employees for Child/Spouse/Domestic
• Partner401K with Employer Match
• Opportunities for Advancement

MINIMUM EDUCATION & EXPERIENCE

• Active, unrestricted registered clinical license required
• 3-5 years of clinical experience required
• Experience with appeals and/or denial processing preferred
• Clinical nursing experience working in a hospital setting – ER, Critical Care, or Diagnostic Services preferred
• CCM (certified case manager), CPUM (certified professional in utilization management) or other relevant certification is preferred

KNOWLEDGE, SKILLS, & ABILITIES

• Critical thinking skills
• Strong oral and written communication skills
• Advanced Microsoft Office knowledge
• Ability to foresee projects from start to finish