Medicare / Medicaid Appeals Registered Nurse to reviews and evaluates medical documentation to support billing compliance and external regulatory requirements. Abstracts pertinent information from the medical record to create appeals for cases denied by governmental payors. Is responsible for the evaluation coordination, and appeal of third party determinations on all levels of the governmental appeal process. Educating department staff to issues related to the reimbursement process, as well as other concerns that result from monitoring activities. Incumbent is also responsible for resolving issues as they occur. Performs other duties as assigned.
Experience Minimum Required:
1. 5 years of healthcare care experience and 3 years in Medicare billing environment.
2. Previous audit experience, knowledge of InterQual and Medicare Billing practices.
Experience Preferred/Desired: None
Education Minimum Required:
1. BSN or RN with BS/BA in Business Administration or Management
2. Strong knowledge of state and federal healthcare laws and regulations.
3. Understanding of CMS coverage and payment methodologies
Special Skills Minimum Required:
1. Excellent oral and written communication skills.
2. Advanced computer proficiency, excellent organizational and time management skills.
Successful demonstration and detailed understanding of Hospital Revenue Cycle, CPT codes, HCPC codes, modifiers, and the Medicare/Medicaid Appeals Process.
LICENSURE, REGISTRATION, CERTIFICATIONS
Familiarity of billing regulations including federal and guidelines.
Must have excellent communication skills and proven ability to present.