Inspire health. Serve with compassion. Be the difference.
Reporting to the Manager of Clinical Audit, the Medical Review
and Appeal RN is responsible and accountable for the evaluation of
claims denials and of appeal activity for Palmetto Health patient
Assesses the need for formal appeals of all clinical denials
including but not limited to pre-authorization of diagnostic and
surgical procedures, admissions, and for retroactive recovery
reviews regarding medical necessity and limited billing
Prepares appeal letters that are accurate, specific, concise,
and conclusive; providing payers with appropriate clinical
documentation as needed. Adheres to all appeal timelines as
prescribed by payer agreements.
Evaluates and adheres to clinical and billing policies,
guidelines and regulations of both commercial and governmental
payers. Also, appeals denials or instructs the resubmission of
claims based on compliant medical record documentation and hospital
policies and procedures.
Hosts insurer audit engagements; opening and preparing accurate
closing documents. Performs medical documentation review and bill
audits and resolves charge capture inquiries initiated by patients
and insurers as needed.
Maintains data and assists with identifying patterns of denial
activity. Monitors payer response to appeal activity. Interacts
with Utilization Management and other clinical departments to
coordinate information for preparation of appeals and with Patient
Financial Services in support of collection activities and/ or in
support of RAC activity contracted to outside physician
Utilizes varied systems to evaluate clinical and financial data
and synthesize information for appeal preparation and data
tracking. (Compliance 360, STAR Financials, Xactimed, ARTIVA,
Allscripts, SOLCOM, EPICenter).
Participates in revenue cycle process improvement projects.
Supervisory/Management Responsibilities This is a non-management
job that will report to a supervisor, manager, director or
executive. Minimum Education Graduate of an accredited school of
Nursing program and approved by the South Carolina State Board of
Nursing required. Bachelor's degree in Nursing preferred Minimum
At least 5 years of hospital nursing required, in an acute care
Licensure, Registry or Certification Required
RN currently licensed in South Carolina.
Other Required Experience
Must possess excellent communication skills, written and oral.
Must be able to think analytically, independently, and objectively.
Must be able to use Microsoft Word and Excel proficiently. Must
have experience with electronic medical record review.
Day (United States of America)
Colonial Life Building
1500 Midlands Corporate
15009012 Patient Account Services
Share your talent with us! Our vision is simple: to transform
healthcare for the benefits of the communities we serve. The
transformation of healthcare requires talented individuals in every
role here at Prisma Health.