Job Description

ECU Health

About ECU Health

ECU Health is a mission-driven, 1,708-bed academic health care system serving more than 1.4 million people in 29 eastern North Carolina counties. The not-for-profit system is comprised of 13,000 team members, nine hospitals and a physician group that encompasses over 1,100 academic and community providers practicing in over 180 primary and specialty clinics located in more than 130 locations.

The flagship ECU Health Medical Center, a Level I Trauma Center, and ECU Health Maynard Children’s Hospital serve as the primary teaching hospitals for the Brody School of Medicine at East Carolina University. ECU Health and the Brody School of Medicine share a combined academic mission to improve the health and well-being of eastern North Carolina through patient care, education and research.

Position Summary

The appeals nurse is responsible for the timely review of denied claims from all payers related to medical necessity, appropriate setting/status determination, authorizations and appropriate length of stay. They will ensure all denied claims are accurately worked and appealed to obtain maximum reimbursement and minimize recoupment. They combine clinical, business and regulatory knowledge and skills to reduce financial risk and exposure caused by concurrent and retrospective denial of payment for rendered services. This position will utilize MCG guidelines, Medicare's 2-midnight rule, and any other payer specific requirement for inpatient, along with the appropriate payer medical policy or NCD/LCD for outpatient services. Medical records may also need to be reviewed for audited claims using the same resources as if the case were denied to prevent recoupment or receive payment related to pre- or post-bill audits. Based on their review, they are responsible for determining whether they will write the appeal, recommend downgrade, or refer to the physician advisors (internal and external) for follow-up. This individual must not only be clinically astute, but well informed on CMS regulations and contract language related to appeal requirements.

Responsibilities

Reviews Medical Record and determines whether each case should be appealed, downgraded, or referred to physician advisors (PAs).

Downgrading would occur if PA indicated in notes or no clinical justification noted in medical record.

Appeals would be written if related to deaths, AMAs, auths due to payer error or when already received.

Appeal referral when a physician is required to support medical necessity.

A medical record review may include investigating a patient's medical and treatment history or obtaining external medical records necessary to support the hospital medical record.

Write comprehensive, concise appeals, utilizing appropriate screening tools and payer policies such as MCG/LCDs/NCDs, etc.

Perform timely medical record audit review for accuracy (retro and prebill).

Track all denial/appeal activity, identifying trends and document outcomes.

Review response letters from insurance carriers and follow-up as necessary.

Minimum Requirements

Bachelor of Science in Nursing.

5 years of related work experience within Case Management, Utilization Review, or Clinical Documentation Improvement.

In place of a Bachelor's in Nursing, an Associate Degree in Nursing (RN) is acceptable with an accompanying 10 years experience in Case Management, Utilization Review, or Clinical Documentation Improvement.

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.

Contact Information

For additional information, please contact:

Angie Nichols, Talent Acquisition Consultant

ECU Health Talent Acquisition

Email: [email protected]