**Job Description** Location: Chicago, Illinois Business Unit: Rush Medical Center Hospital: Rush University Medical Center Department: Patient Access-Pre-Visit **Work Type:** Full Time (Total FTE between 0.9 and 1.0) **Shift:** Shift 1 **Work Schedule:** 8 Hr (8:00:00 AM - 4:30:00 PM) Rush offers exceptional rewards and benefits learn more at our Rush benefits page (https://www.rush.edu/rush-careers/employee-benefits). **Pay Range:** $34.98 - $58.77 per hour Rush salaries are determined by many factors including, but not limited to, education, job-related experience and skills, as well as internal equity and industry specific market data. The pay range for each role reflects Rush’s anticipated wage or salary reasonably expected to be offered for the position. Offers may vary depending on the circumstances of each case. **Summary:** This position reviews initial clinical facility and physician denials, documents appeals for clinical inpatient denials, conducts appeals as appropriate. Track denial outcomes, identify trends and work collaboratively with clinical providers, coders, insurance companies and revenue cycle leadership to prevent future clinical denials by communicating denial root causes and help develop education and process changes. Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures. **Other information:** **Required Job Qualifications:** • Licensed, registered nurse in the State of IL with at least 5 years of experience in clinical setting. • Knowledge/experience in utilization management, denials or appeals management in hospital or physician denials desired. • Knowledge of clinical criteria for medical necessity; hospital & physician revenue cycle; and compliant coding/billing practices. • Extensive knowledge of federal, state and payer specific regulations and policies pertaining to documentation, coding and billing, with demonstrated ability to interpret such guidelines. • Demonstrates an advanced knowledge and skill in analyzing patient records to identify non-conformances in CPT, ICD-10 CM and HCPCS code. • Knowledge of Epic applications with focus on Resolute Hospital Billing. • Clear and concise verbal and written communication skills. • Math skills. • Experience multi-tasking. • Organized, attentive to details, and self-motivated. **Preferred Job Qualifications:** **Physical Demands:** **Competencies:** **Disclaimer:** The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements. **Responsibilities:** 1. Conducts medical necessity reviews and prepares any required clinical documentation summaries to accompany appeals to ensure optimal reimbursement. 2. Reviews clinical information, claim charges, forms and insurance correspondence when reviewing governmental and non-governmental clinical denials to determine if coding, billing, claim follow-up, payment posting are accurate and supported by documentation before initiating appeals process. 3. Monitors and follows up on appeals throughout entire process to ensure appeal has resulted in an overturned denial or has escalated through the proper channels. 4. Assist Utilization Management and Denials Management on implementing a strong process that will help prevent claim denials and lodge successful requests for appeals. 5. Establishes collaborative relationships with physician leaders, clinical providers, IS, Corporate Compliance, Revenue Cycle and administrative leadership in support of coding education and documentation adequacy. 6. Analyzes denial trends to identify incomplete or inconsistent documentation that impacts the quality of our appeals and assists in the development of corrective action plans. 7. Maintains accurate, clear, timely documentation related to denied cases. Manages Care Management denial management database. Tabulates the financial gains of the position and opportunities for improvement. 8. Participates in the policy and procedure decision-making process and adheres to all policies and procedures set forth by the Care Management Department and Rush University Medical Center. 9. Coordinates clinical appeals process and participates in in compliance investigations as needed for RUMC and ROPH including payer contacts, OIG/RAC correspondence, summary documentation of status and action taken, follow-up activities, and internal tracking. 10. Develops, implements and evaluates processes to ensure accurate and timely collection of information. Identifies billing-related issues and works with the payers, Care Management, Finance, physicians and staff to resolve issues in a timely manner. 11. Identifies denial avoidance and assists in the development of corrective action plans and process improvements. Provides results reporting and communication. Tracks outcomes, shares results, identifies trends, and presents strategies. 12. Adheres to service principles with customer service focus on I-Care values when responding to patients, insurance companies and other offices for hospital related services inquiries regarding denials and appeal complaints or inquiries. 13. Works with and provides education for staff, physicians, and payers on reimbursement issues, clinical protocols/criteria, insurance plan changes, regulations and process improvements based on supporting documentation. 14. Serves as a resource, maintains expertise and continues self-education by attending applicable conferences, workshops and interdisciplinary meetings. 15. Utilizes local, regional and national forums to continuously enhance expertise and knowledge base. 16. Participates in applicable professional organizations and committees. Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics. **Position** Appeal Specialist RN **Location** US:IL:Chicago **Req ID** 15356