RN Clinical Validation Appeals Specialist

SUMMARY:

The Clinical Validation Appeals Specialist is responsible for: appealing clinical validation denials to enhance revenue cycle management; tracking denial trends, identifying continuous improvement opportunities; developing and providing educational training for physicians, CDI and Coding staff; and providing input on TMC’s contract negotiations with payers specifically related to clinical validation and appeal rights.

ESSENTIAL FUNCTIONS:

Investigates and analyzes clinical validation denial letters and medical records using medical investigative skills to determine if there is support for an appeal based on clinical evidence in the medical record, the Official Coding Guidelines, AHA Coding Clinic, and TMC internal policies and procedures.

Researches and reviews medical literature and coding references and literature to develop arguments for appeals.

Drafts first and all subsequent appeal letters to reviewing companies and/or Plan providers.  Pursues Peer to Peer reviews of denials when allowed and appropriate.

Develops and drafts documents for administrative hearings in collaboration with relevant TMC staff.

Prepares witnesses for administrative hearing testimony and attends the hearing with relevant witnesses.

Tracks clinical validation denial categories to identify payer trends and opportunities for improvement.

Based on trends, develops and delivers educational materials to the relevant health care providers, i.e., physicians, nurses, dieticians, and others.

Develops strategies for refuting appeals, including Peer to Peer reviews, discussions/negotiations with Plan providers, and mediation or arbitration.

Functions as key TMC representative/liaison in meetings with Payers regarding clinical validation denials and the appeal process.  

Coordinates and collaborates with Coders and CDI via monthly meetings and on a case by case basis.

Partners with CDI team to analyze denial trends and TMC policy and procedures to develop and implement innovative changes 

Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication. 

Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards. 

Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION:  Bachelor degree in nursing required. Additionally, Juris Doctorate (JD) from an accredited school of law preferred.

EXPERIENCE:  Three (3) years of Medical/Surgical nursing experience in an acute hospital setting. 

LICENSURE OR CERTIFICATION: Current RN licensure permitting work in state of Arizona.

KNOWLEDGE, SKILLS AND ABILITIES: 

• Ability to analyze and interpret regulatory guidelines and Payer contracts.

• Ability to identify medical and regulatory appealable issues and evaluate facts, regulations, and research to develop concise, persuasive arguments for appeal.

• Ability to rapidly assimilate and analyze complex information from many sources and apply principles of deductive reasoning.

• Strong working knowledge of all areas of adult medicine, anatomy and physiology as it relates to the acute hospital setting.

• Excellent verbal and written communication skills.

• Requires critical/analytical thinking and problem solving skills.

• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.

• Ability to calculate figures and compute rate, ratio, and percent and to draw and interpret bar graphs and apply basic algebraic concepts.

• Ability to collect and analyze data for tracking and trending to identify opportunities for improvement.

• Ability to work collaboratively across functional groups to achieve successful financial and patient quality outcomes