The Director, Clinical Appeals Nurses is responsible for providing consultative, educational development, and support services to the acute care facilities and affiliates regarding clinical appeals for medical necessity denials. This position is accountable for the design and implementation of the clinical appeals writing and directs the activities of the Clinical Appeals Nurses. The Director will work closely with the members of the Appeals Management Team, Recovery Audit Contractors and PFS staff to ensure the operational goals of the Appeals Management Team are achieved. The Director will be engaged in all strategic planning to tie clinical appeals management to the business and clinical operations of CHRISTUS Health.
Manages daily activities related to the clinical appeals function, ensuring processes are performed efficiently and effectively
Assures staff writings are supported by current industry clinical guidelines, evidence based medical, community and national medical management standards and protocols
Assures appropriate action is taken within appeal time frames to address clinical denials
Analyzes trends of clinical denials and work with the RAC and insurance companies to resolve underlying reasons for denials
Reviews staff associates productivity on a monthly basis and assist with annual evaluations
Acts as a liaison between the clinical appeals staff, PFS, and the facility case management directors
Resolve issues escalated by Clinical Appeals staff
Attends administrative law judge hearings as needed and maintains documentation of the meetings
Creates and identifies trends in patterns from clinical appeals activities
Graduate of an accredited School of Nursing with a Bachelor's degree in nursing or health related field.
Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task
Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff).
Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomes
Assertive and diplomatic communication, proven ability to function on a multidisciplinary team.
Excellent organizational skills including effective time management, priority setting and process improvement.
Two to four years of Utilization Review/Case Management experience.
Two-three years' experience in the denial and appeal process.
Experience with managed care, governmental and/or RAC appeals strongly preferred.
Knowledgeable of InterQual and Milliman Care Guidelines (MCG) medical necessity criteria
Understanding of Medicare, Medicaid and third party reimbursement methodologies.
Experience in writing clinical denials
Computer experience in Microsoft Office (Word and Excel).
Current RN Nursing license
Interqual and/or MCG certification preferred. Case Management certification preferred
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.