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 recordsPrioritize denials based on expiration dates and dollar amountCommunicate with all responsible parties regarding missing or insufficient medical documentationMake referrals to Medical Director for physician level reviewsReview 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 providedDocument UM team involvement and appeal process in star and UM denial moduleCollect 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 trendsWork with department manager to orient an onboard new team membersPerform 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 membersPerforms other duties as assignedComplies 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 andBachelor'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 andMinimum 3 years experience as a staff nurse in an acute care setting Required

Required Minimum Skills:

Proficient in typingExperience with Microsoft Office suiteAbility to learn and understand various clinical software applicationsStrong clinical judgment and multitasking abilityExcellent problem-solving skillsSelf-motivation and ability of working independently with limited supervision and structureExcellent 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.