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RN-Medical Review & Appeal

Company: Prisma Health Upstate
Location: Columbia
Posted on: October 17, 2020

Job Description:

Inspire health. Serve with compassion. Be the difference.

Job Summary

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 accounts.


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 compliance.

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 advisors.

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 Experience

At least 5 years of hospital nursing required, in an acute care settings preferred.

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.

Work Shift

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.

Keywords: Prisma Health Upstate, Columbia , RN-Medical Review & Appeal, Other , Columbia, South Carolina

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