Senior Clinical Appeals - RN - Remote Job Plymouth Minnesota USA,Healthcare

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives?

Join us to start Caring. Connecting. Growing together.

The Senior Clinical Appeals RN utilizes subject matter expertise in MS-DRG and APR-DRG auditing to review and provide response to appeals. By partnering with the original auditor, review medical records, and other information to author a rebuttal or agreement with the facility. This person will be instrumental in providing coaching and education to our remote DRG Validation Specialists utilizing core coding and clinical information.

We are seeking self-motivated, solution-oriented and skilled problem solvers who provide written documentation under tight deadlines. As a Sr Clinical Appeals RN, you will derive key insights from the appeals and provide guidance and direction to fellow auditors across our business.

You’ll enjoy the flexibility to work remotely
* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

Analyze scope and resolution of DRG Appeals
Respond to Level one, two or higher appeals
Perform complex conceptual analyses
Identify risk factors, comorbidities, and adverse events, to determine if over payment or claim adjustment is needed
Review governmental regulations and payer protocols and / or medical policy to recommend appropriate actions
Research and prepare written appeals
Exercise clinical and/or coding judgment and experience
Collaborate with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims
Navigate through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel
Serve as a key resource on complex and / or critical issues and help develop innovative solutions
Define and document / communicate business requirements

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Unrestricted RN (registered nurse) license in your state of residence
CCS or CIC certification or willing to obtain within 6 months of hire
2+ years of ICD
-10-CM coding including but not limited to; knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
2+ years of ICD-10-PCS coding including but not limited to; knowledge of the structural components of PCS including but not limited to; selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers

Preferred Qualifications:

An existing coding certification, such as RHIT (registered health information technician), RHIA (registered health information administrator), CDIP (certified documentation improvement practitioner), CCS (certified coding specialist), or CIC (certified inpatient coder)
3+ years of MS DRG/APR DRG coding experience in a hospital environment with knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
Managed care experience
Healthcare claims experience
Investigation and/or auditing experience
Knowledge of health insurance business, industry terminology, and regulatory guidelines
Profici…