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Job Information

HCA, Hospital Corporation of America Clinical Appeals Nurse in Nashville, Tennessee

Do you want to join an organization that invests in you as a Clinical Appeals Nurse?At Parallon, you come first. HCA Healthcare has committed up to $300 million to our incredible team members over the course of three years. We are committed to providing our employees with the support they need.

At Parallon, we offer an array of medical, dental, and vision packages as well as several add-on perks to make your benefits package truly customizable to you and your family needs. Some of our unique benefits we offer include: * Tuition Reimbursement/Assistance Programs/Student Loan Repayment * Paid Personal Leave * 401k (100% annual match – 3%-9% of pay based on years of service) * Identity Theft Protection discounts * Auto, Home, and Life Insurance options * Adoption Assistance * Employee Stock Purchase Program (ESPP) You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Clinical Appeals Nurse like you to be a part of our team.

Job Summary

The Clinical Appeals Nurse is responsible for providing clinical input or interpretation for denials that have remained unresolved or have been escalated under the Shared Service Center (SSC) operations pre-established protocols. This position will be critical in supporting the dispute resolution strategy focused on denial cash conversion.**Tracking large case volumes efficiently and effectively, with technology, while providing the highest levels of customer service and attention to details is required.

Duties (included but not limited to):

  • Compose, edit, review, or otherwise support concise clinical evaluations for disputed claims through review and assessment of denial reconsideration documentation, payer denial documentation, medical records, other relevant documents; recommend next steps for resolution.
  • Demonstrate understanding of use of all Medical Necessity software, including but not limited to InterQual©.
  • Demonstrate ability to interpret medical payer policy requirements.
  • Strong ability to research evidence-based practices.
  • Contact appropriate parties (internal and/or external) as needed for additional information to properly formulate and evaluate a clinical summary.
  • Utilize computer programs and software to ensure assigned cases are tracked and monitored in an efficient and effective manner.
  • Review and apply contract language as necessary to clinical summaries.
  • Utilize payer administrative manuals to dispute denied claims.
  • Maintain and apply understanding of federal, state and local rules and regulations impacting denials.
  • Maintain and apply understanding of HCA / Parallon policies and procedures and work protocols impacting denials.
  • Communication - communicates clearly and concisely, verbally and in writing. This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately.
  • Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
  • Interpersonal skills - able to work effectively with other employees, patients and external parties
  • PC skills - demonstrates proficiency in Microsoft Office applications and others as required
  • Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems
  • Basic skills - able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
  • Clinical skills – ability to read and interpret medical records
  • Quality - Demonstrates accuracy and thoroughness in a fast-paced work environment; Looks for ways to improve and promote quality
  • Technical –Ability to learn and master new computer programs/software quickly.

  • Bachelor Degree preferred

  • At least one year case management or similar appeal experience required
  • Relevant education may substitute experience requirement
  • State RN or LPN License required (Active/Inactive)

Parallon believes that organizations that continuously learn and improve will thrive. That’s why after more than a decade we remain dedicated to helping hospitals and hospital systems operate knowledgeably, intelligently, effectively and efficiently in the rapidly evolving healthcare marketplace, today and in the future. As one of the healthcare industry’s leading providers of business and operational services, Parallon is uniquely equipped to provide a broad spectrum of customized revenue cycle services.

We are a wholly owned subsidiary of HCA Healthcare, a comprehensive healthcare network where over 265,000 people across more than 1,800 care facilities are all committed to creating a positive impact every day. It’s an organization that exists to give people healthier tomorrows. HCA Healthcare has been continually named a World's Most Ethical Company by Ethisphere since 2010. In 2018, HCA Healthcare spent an estimated $3.3 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Clinical Appeals Nurse opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Job: *Case Management

Title: Clinical Appeals Nurse

Location: Tennessee-Nashville-Corporate Parallon

Requisition ID: 10251-5069