The Appeals and Medical Review Nurse works closely with the clinical, financial departments and physicians to minimize the impact of denials through preparing and overseeing the appeals efforts in the organization. This requires a strong clinical background, diligence in research and attention to details.
Review records for any accounts that have been denied for medical necessity and provide feedback as to the appropriateness of the status of the account.
Evaluation of denials received occur within 5 working days of receipt
Records are reviewed to determine if appeal is feasible based on medical necessity
Questionable cases are reviewed with Director
Records are prepared for appeal submission
Work closely with the utilization review staff, physicians and Executive Health Resources staff to complete the appeals process.
Effective relationship with Utilization Review staff
Upload cases to EHR portal to ensure timely processing of appeals
Download communications from EHR on a daily basis and update accounts with any new information received
Close accounts that have been overturned or all levels of appeal have been exhausted
Review processes involved in clinical documentation into the electronic record for opportunities for improvement and prevention of denials.
Work closely with the physicians to ensure compliance with documentation requirements
Contact physician offices to obtain additional information if needed
Develop standard documentation templates for physicians to ensure all required elements of documentation are captured
Demonstrates knowledge of utilization review practices, including application of Interqual criteria, standards of medical care, local and national coverage determinations and contract terms.
Utilize Interqual criteria to ensure correct statusing of accounts and appropriate continued stay
Review NCD and LCD on regular bases to ensure that up to date requirements for medical necessity documentation are communicated to physicians
Familiar with contract terms for major payers
Identify and report trends in initial and concurrent review process contributing to denials
Consistent favorable guest relations and customer service.
Positive team spirit through optimistic comments about the care management, the profession of nursing, and Good Shepherd Medical Center.
Excellent public relations externally and internally.
Satisfaction with service as evidenced by favorable survey results, personal visits, etc.
All complaints are responded to in an appropriate and timely manner.
Maintenance of patient rights and function as patient advocate
Adherence to the GSMC professional dress code policy
Compliance with applicable laws, regulations, and accreditation standards.
Knowledge of regulatory and payer requirements
Improvement in patient care demonstrated through quality assessment and improvement program.
Evidence of safe work practices.
Accident-free work environment.
Demonstration of concern for the esthetics of the hospital
Incorporates, evaluates, promotes, and participates in research into the practice setting
Demonstration and assurance of competence as appropriate to the ages of the patients
Ability to meet the needs of the patient, family and others.
Knowledge of growth and development and its relationship to treatment.
Consistently combines an awareness of patients' rights and ethical judgement for following through with appropriate action to function as a patient advocate.
Knowledge of Code of Ethics policy and procedure
Identifies and reports ethical issues following appropriate chain of command
Our Mission: WHY WE EXIST. To extend the healing ministry of Jesus Christ. Our Core Values: WHAT WE BELIEVE IN.DIGNITY Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. INTEGRITY Honesty, justice, and consistency in all relationships. EXCELLENCE High standards of service and performance. COMPASSION Service in a spirit of empathy, love, and concern. STEWARDSHIP Wise and just use of talents and resources in a collaborative manner.Our Vision: WHAT WE ARE STRIVING TO DO. CHRISTUS HEALTH, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God's healing presence and love. Our Name and Symbol:WHO WE ARE. CHRISTUS is Latin for "Christ," and proclaims publicly the core of our mission. OUR NAME choice also recognizes the heritage of our two congregational sponsors, the Sisters of Charity of the Incarnate Word in Houston and San Antonio. Jesus Christ is the Incarnate Word, the Word of God made flesh. It is, theref...ore, only fitting that it is in another form of His name that our health ministries are called together. OUR SYMBOL Reflects the healing ministry of Jesus Christ - a combination of a medical cross and a religious cross. The flowing banner on the cross is a common symbol of the risen Christ, while the royal purple signifies Christ. The flowing banner also conveys a sense of motion as we move forward into a new era of service to our communities.