Clinical Appeals LVN

Job Summary : The Clinical Appeals LVN is responsible for day-to-day review, coordination and management of clinical denials requiring background and understanding from a provider operational and payer logistical perspective. The Clinical Appeals LVN must work with a diverse group of other health care professionals to conduct review and appeal of clinical denials concurrently and post billing, related to all Payor plans. The appeals nurse must have knowledge across multiple departments including Sub Acute and Behavioral Health units. Represents Pipeline Health hospitals from a system perspective when working with payers to challenge and overturn denials of clinical nature. Manages overturn rate data and evaluates trends for improvement opportunities. Works as part of the team to develop meaningful information for hospitals and other stakeholders to improve operational performance and cash collections. The Clinical Appeals LVN must have knowledge of government / State policies and should have strong project management and analytical skills and be able to handle projects simultaneously. The Clinical Appeals LVN should be able to work well individually or as part of a team. Assisting with chart and defense audits with outside payors and with CDM charge and coding reviews.

Essential Functions :

• Evaluates all Clinical denials for possible overturn opportunity. Prepares Appeals as required. Follow up with and work closely with payers both on the phone and through electronic means to resolve denials and receive payment on accounts.
• Works as part of a team to develop and administer all Clinical denial workflows and processes.
• Works closely with Case Managers and Collection Manager to review cases and provide guidance in understanding the interplay between clinical and technical denials.
• Tracks and manages denied accounts, including triaging denials with the Case Managers and Collections Manager to evaluate collectability quickly and expeditiously.
• Based on initial review of accounts, manages various "buckets" of issues across Hospitals to resolution.
• Identifies and escalates consistent issues and trends with payers to support Leadership when meeting with payers to resolve issues.
• Provides fact-based information to Leadership on a regular basis on Clinical denial performance with recommendations on process improvements to avoid denials in the future.
• Complies with Federal, State, and Local Laws that govern business practices.
• Understands and abides by all departmental policies and procedures as well as the Code of Ethics, HIPAA requirements and patient rights.
• Performs other job-related tasks, and special projects as assigned.
• Assists with chart and Defense audits with outside payors.
• Assist with CDM charge and coding reviews.
• Assists with disputes and reviews and discusses with patients.
• Documents findings in financial systems and in report excel format.
• Works correspondence pertaining to Clinical denials.
• Communicates with Billing and Collections departments, and other Revenue Cycle departments.
• Creatively applies job knowledge and experience to solve difficult problems and regularly provides suggestions for quality improvement.
• Works with Leadership to recommend ways to maximize the use of the department to support strategic and operational needs of the Hospital.
• Works with Leadership to identify training and system gaps and develop strategies to address these gaps.
• Complies with Federal, State, and Local Laws that govern business practices.
• Performs all other duties as assigned.

Behavioral Standards :

Communication / Knowledge :

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