Appeals Nurse Reviewer

Job Description:

Across from the University of South Florida, you'll find University Community Hospital the flagship of University Community Health. This 431-bed facility is home to our six centers of excellence focusing resources on major disease areas including cancer treatment, cardiac care, women's health, pediatrics, diabetes management and orthopedics, and offer patients access to the most advanced technology and treatment options. Although we employ a staff of over 3,000 and provide the expertise of nearly 900 physicians and more than 50 different specialties, we strive to maintain a family atmosphere.  

In addition, University Community Hospital offers several specialized service units including intensive care, pediatric/neonatal intensive care, rehabilitation, occupational health, continuing care and orthopedic, pediatric and general surgery as well as a 24-hour emergency department with dedicated treatment facilities for chest pain, pediatrics and minor care.

Job Requirements:

REQUIREMENTS INCLUDE:Education

• BSN preferred, or comparable work experience and continuing education preferred.

• Registered Nurse with current Florida License.
• CCM or other Case Management certifications preferred.

• Three (3) to five (5) years Managed Care experience.
• Experience with data analysis and interpretation.
• Experience with PC applications required (MS Office Products).
• Knowledge/experience with ICD-9, CPT, DRG and Revenue codes.
• Familiarity with Managed Care contracts and policies/procedures.

• Excellent communication skills required.
• Strong interpersonal and management skills required.
• Must possess and exercise initiative, good judgment and discretion.

Job Responsibilities:

The Appeals Nurse shall be responsible for getting Managed Care denials overturned/reversed by constructing compelling appeals based upon review of InterQual Criteria and clinical nursing judgment as well as the medical necessity of services delivered. Responsible for the review of all existing documentation such as: UB, IB, EOB, and Managed Care contracts to verify claim balance calculation and to ensure integrity in documentation. The Appeals Nurse shall audit medical records, interact with appropriate University Community Health departments (Patient Access, Case Management, Patient Business Services, Medical Records) to assemble appeals and to represent University Community Health in meetings with Plans to achieve payment. The Appeals Nurse must possess the ability to detect issues causing denials and constructively report to those parties/areas/departments to assist in resolution. Professional persistence is an essential requirement.

Job Benefits:

At University Community Health, we are dedicated to providing outstanding patient care. That is why our mission is to recruit and retain the best employees. We offer comprehensive benefits, a competitive wage program and a team of dedicated employees. Join our team of expert healthcare professionals!  

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