The Appeals Nurse is primarily responsible for clinical oversight of the appeals process.
* Reviews appeals packet received from physician office to ensure that it contains all required components
* Reviews appeals documents received and develops an appeals letter
* Performs research as needed to obtain pertinent information for use in appeals documentation and to educate herself/himself on disease process
* Collaborates with physicians and their staff as needed to obtain clinical information in order to complete appeals letter
* Once appeals letter is complete, facilitates submission of documents to payer
* Maintains up-to-date documentation of all aspects of clinical oversight process in patient database
* Provides guidance to staff and physicians on clinical aspects of the appeals process
* Maintains literature database
* Maintains monthly expense report of articles purchased for use in appeals packets and submits to appropriate personnel monthly and as requested
* Maintains state required nursing CEUS and seeks continuous learning opportunities
* Insurance follow-up calls
* Other duties as assigned
*Minimum (Required) Qualifications:*
* Associate’s degree in a related field
* Active RN License, in the state worked
* Minimum of 3 to 5 years of experience in either case management, or claims adjustment.
* Experience in disease or therapy as it applies to assigned appeals
* Ability to read, analyze and interpret profession journals, technical procedures, product instructions or governmental regulations
* Ability to communicate clearly in both written and oral communication
* Strong computer skills required; preferably Microsoft Word orExcel software applications
* Demonstrate high level of integrity and professionalism to handle sensitive and confidential information
* Attention to detail
* Ability to utilize clinical critical thinking skills to systemically collect, verify, analyze and communicate data to enable the delivery of evidence-based nursing interventions
*Preferred Qualifications:*
* Bachelor’s degree preferred
* Customer service experience
* Insurance experience
*Physical Demands:*
May sit, stand, stoop, bend and walk intermittently during the day. May sit or stand seven (7) to ten (10) hours per day. May be necessary to work extended hours as needed. Finger dexterity to operate office equipment required. May need to lift up to twenty-five (25) pounds on occasion. Visual acuity to see and read fine prints. Specific vision abilities required by this role include close vision, color vision and the ability to adjust focus. Must be able to hear normal voice sounds. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this role.
*Work Environment:*
Work in a climate-controlled, smoke-free internal environment.
*Equal Opportunity Employer: * Omnicare is fully committed to employing a diverse workforce. We recruit and retain talented individuals without regard to gender, race, age, marital status, disability, veteran status, sexual orientation and gender identity or any other status protected by federal, state or local law. Omnicare is an Equal Employment Opportunity and Affirmative Action Employer.
EO/Minorities/Females/Disabled/Veterans
Omnicare, Inc. is a wholly owned subsidiary of CVS Health Corporation. www.cvshealth.com
*What We Do*
Directly, and through our subsidiaries, Omnicare provides a broad array of pharmacy-related services to long term care facilities and to other customers in the health care environment. While senior care has long been an Omnicare specialty, we also serve other targeted populations.
*Commitment at Every Level*
A large part of Omnicare's success derives from a commitment, at every level, to the welfare of each individual we serve. Each day, our employees consider how their work can improve the quality of life of residents and patients. Omnicare is truly a health care company, working to improve the health and quality of life for everyone we touch.