Search Open Positions
Revenue Cycle Appellate, Clinician - Remote
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
The Revenue Cycle Clinician for the Appellate Solution is responsible for:
- Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
- Preparing and documenting appeal based on industry accepted criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
- Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
- Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
- Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process.
- Adhers to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines.
- Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office.
- Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc
- Additional responsibilities:
- Serves as a resource to non-clinical personnel.
- Provides CRC leadership with sound solutions related to process improvement
- Assist in development of policy and procedures as business needs dictate.
- Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Demonstrates proficiency in the application of medical necessity criteria, currently InterQual®
- Possesses excellent written, verbal and professional letter writing skills
- Critical thinker, able to make decisions regarding medical necessity independently
- Ability to interact intelligently and professionally with other clinical and non-clinical partners
- Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms
- Ability to multi-task
- Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
- Ability to conduct research regarding off-label use of medications
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience required to perform the job.
- Must possess a valid nursing license (Registered or Practical/Vocational)
- Minimum of 5 years recent acute care experience with the last 2 years in a facility environment
- Medical-surgical/critical care experience preferred
- Minimum of 2 years UR/Case Management experience within the last 2 years
- Managed care payor experience a plus either in Utilization Review, Case Management or Appeals
- Patient Accounting experience a plus
- Previous classroom led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred
CERTIFICATES, LICENSES, REGISTRATIONS
- Current, valid RN/LPN/LVN licensure
- Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred
Employment practices will not be influenced or affected by an applicant’s or
employee’s race, color, religion, sex (including pregnancy), national origin,
age, disability, genetic information, sexual orientation, gender identity or
expression, veteran status or any other legally protected status. Tenet will
make reasonable accommodations for qualified individuals with disabilities
unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program. Follow the link below for additional information.
Jobs for You
- Patient Account Representative - Remote Job ID: 2105031488 Date posted: 09/10/2021 Facility: Conifer Health Solutions
- Patient Account Senior Representative - Remote Job ID: 2105031079 Date posted: 09/10/2021 Facility: Conifer Health Solutions
- Patient Service Center Representative II- Remote Job ID: 2205001262 Date posted: 01/14/2022 Facility: Conifer Health Solutions
Tenet - A Community
Built on Care.
Across the country, the Tenet family includes 110,000 employees working in more than 65 hospitals and over 475 outpatient centers. We’re all focused on delivering the right care in the right place at the right time.
At Tenet, the impact of our work spreads far and deep across the many dimensions of healthcare that we touch. Every day, our employees and physicians foster a compassionate environment for care and healing in the communities we serve. We take pride in what we do, we are passionate about our chosen path, and we take seriously the true privilege we have in serving others as a Community Built on Care.Learn About Opportunities Across Tenet