Clinical Appeals Nurse FT/40 HRS - Santa Fe - (Santa Fe, NM)

Description Responsible for the management and communication of denials/appeals received from 3rd party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing all inappropriate denials through all possible levels of the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.