**Description** _Summary:_ Responsible for the management and communication of denialsappeals received from third party payers, managed care companies, andor government entitiesauditors related to medical necessity andor 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 identifiedreferred for appeal based on Milliman Care Guidelines (MCG), InterQual, andor 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 denialappeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with Case Management leadership, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denialsappeals will be reported to the facility. _Responsibilities:_
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...Customer Service - Aetna Answer Team Consultant at CVS Health in Boise, Idaho, United States... ...as what we deliver. Our Heart At Work Behaviors support this purpose. We want everyone... ...client. Required Qualifications - Work From Home. - Prior Call center experience. -...
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POSITION SUMMARY: The Hospice RN Per Diem Nurse is responsible for providing skilled nursing and other therapeutic services using hospice... ...of Nursing. Bachelor#s degree, preferred. Must have a current Registered Nurse license with the state of Connecticut. Possession of an...