Incumbent is responsible for planning, directing and overseeing all aspects of Clinical Appeals and Charge Audits. The Clinical Appeal Nurse will be in charge of initiating the appeal process and developing victorious appeal letters to support medical necessity or level of care. Provides necessary training and education to staff involved in processes and ensures standards complies with federal, state and other regulatory agency rules and regulations. Works with Care Management leadership and Physician Advisors to ensure knowledge of denial to improve impactful areas. Actively participates on organizational performance improvement projects. Serves as a role model and resource to colleagues, staff and others.
Rate Minimum $68,500.00 Maximum $140,200.00
3 year experience with InterQual/MCG Guidelines required
3 years' working in an Acute Hospital Utilization Management, Concurrent Review Process or Care Management area
Ability to establish and maintain effective working relationships across the HealthSystem
Ability to maintain a work pace appropriate to the workload
Bachelor of Science in Nursing
Demonstrated ability to lead change and effectively manage conflict
Excellent analytical skills
Excellent working knowledge of desktop computer productivity tools
Excellent written and verbal communication skills in English
Experience generating victorious Appeal Letters
Knowledge of CMS, DHCS, Joint Commission, CADP, and other regulatory and compliance requirements
Must demonstrate customer service skills appropriate to the job
Must possess the skill, knowledge and abilities essential to the successful performance of assigned duties
Outstanding interpersonal skills; ability to interact effectively at all levels of the organization
Proficiency in Microsoft Office suite
Strong knowledge and understanding of ICD-10 and CPT codes
Knowledge of University and Medical Center organizations, policies, procedures and forms
Knowledge of patient safety strategies
Knowledge of quality improvement methodologies
Physical, Mental & Environmental Demands:
To comply with the Rehabilitation Act of 1973 the essential physical, mental and environmental requirements for this job are listed below. These are requirements normally expected to perform regular job duties. Incumbent must be able to successfully perform all of the functions of the job with or without reasonable accommodation.
Since 1965, the University of California, Irvine has combined the strengths of a major research university with the bounty of an incomparable Southern California location. UCI's unyielding commitment to rigorous academics, cutting-edge research, and leadership and character development makes the campus a driving force for innovation and discovery that serves our local, national and global communities.