拒付管理上诉护士（麻醉）

Company Overview
Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families.
With 20+ hospitals, outpatient clinics, ambulatory care centers and outreach locations across the globe, we provide excellent care to children up to age 18 regardless of their family’s ability to pay or insurance status. Please click here to learn more about our locations.
Job Description
The Denials Management Appeals Nurse (Anesthesia) is responsible for managing our medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Denials Management Appeals Nurse (Anesthesia) will utilize their clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials.
The Denials Management Appeals Nurse (Anesthesia) is also responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals in accordance with Third party and governmental contracts
Key Responsibilities:

• Performs a review of assigned cases comparing the bill to the medical record.

• Performs a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process

• Performs a detailed comparison of charges to documentation to ensure services not documented are not charged.

• Reviews documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur

• Review findings with the hospital representatives and obtains an agreement on the discrepancies.

• Demonstrates tact and understanding in handling problems, has a good rapport with hospital and corporate staffs.

• Follows up on appeals in a timely fashion to ensure that cases are completed.

• Re-checks mathematical computations before finalizing letter and report.

• Updates status of all cases assigned on minimum weekly basis

• Informs supervisor of any changes, problems, or concerns that arise at a facility.

• In the event of a dispute with the requesting party’s audit findings, files an appeal with the third party or governmental payor

• Analyzes and interprets all medical necessity/clinical denials from third party payors or governmental payors.

• Files appeals based on medical documentation and interpretation of medical necessity guidelines or InterQual criteria.

Required Qualifications:

• 5 years of clinical healthcare/hospital experience

• 3 years of related Anesthesia experience

• Third Party Payor Appeals/Revenue Cycle experience

• Current RN license in State of employment

• Working experience with Utilization Review activities and general knowledge of TJC, PRO, and other regulatory bodies.

• High School Diploma/GED

Preferred Qualifications:

• Bachelor’s degree - BSN highly desired

• Case Management certification

• Experience reviewing hospital and professional claims, denials and EOB's, appealing claims and working on claims in an audit

• Experience with Epic, Craneware, Waystar, software and applications

The pay range for this position is $80,912.00 - $121,388.80. Compensation is determined based on years of relevant experience and departmental equity.Originally posted on Himalayas