Clinical Review Nurse - Remote

Company: Aspirion
Location: Raleigh
Posted on: January 16, 2022

Job Description:

Aspirion's Clinical Review Nurse advocates for reimbursement for services provided by the hospital through their review and analysis of complex medical issues. Accountable for carrying a queue of assigned accounts. Review and analyze medical records to formulate complex clinical arguments. Support Operations and Client Management by providing feedback on medical trends, issues, and denials.

DUTIES AND RESPONSIBILIITES:

• Manages complex and robust queue according to Aspirion and client needs. Queue size varies weekly.
• Conducts weekly reviews and responsible for escalating foreseeable obstacles.
• Complies with timely filing deadlines as provided by Aspirion attorneys.
• Assists with short-notice timely filing deadlines.
• Reviews extensive, high dollar claims and collaborate with Management in addressing the medical components of said claims.
• Reviews medical records and documentation pertaining to Aspirion account work within Aspirion Shared Drives or directly in Client System.
• Participates in required Client System trainings.
• Reviews insurance denials, including but not limited to, medical necessity denials, patient status denials (i.e., Inpatient vs. Outpatient Observation), level of care denials (i.e., bed type), length of stay denials (including stays over a month long), readmission denials, experimental denials, clinical validation denials, and/or authorization denials.
• Reviews and utilizes clinical criteria, including but not limited to, InterQual, Milliman Care Guidelines ("MCG"), UpToDate, Medicare Policies, and State Specific Clinical Criteria.
• Drafts clinical summaries, including but not limited to, arguing against an insurance denial, confirming an insurance denial, or reviewing a clinical determination.
• When performing clinical reviews, monitors hours expended on a single account to ensure the time invested is commensurate with the account's potential reimbursement and check in with Managing Attorney when time expended exceeds average hours for type of review.
• Identifies and tracks common trends and issues for reporting to the clients.
• Provides feedback regarding common trends and issues.
• Contributes to Quarterly Nurse Feedback Memorandum, Issues and Recommendations Reports, and other potential projects.
• Collaborates with Aspirion attorneys via in person meetings, phone, and/or email.
• Answers questions pertaining to clinical analysis of accounts.
• Advises Aspirion attorneys and employees about clinical analysis.
• Compiles training material and educational sessions associated with clinically related topics and present such educational materials to Aspirion attorneys.
• Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings.
• Participates in Monthly Chat Sessions.
• Appropriately utilizes and updates Aspirion's eCollections software.
• Awareness of and adherence to Aspirion policy and procedures.
• Adheres to HIPAA compliance rules and regulations.
• Responsible for reporting any violations relating to company policy protocol.
• Responsible for escalating IT issues to Managing Attorney.
• Performs additional duties as assigned.
  
  Requirements
  
  EDUCATION AND EXPERIENCE QUALIFICATIONS:
  
  • Requires an AS/BS in nursing.
  • Minimum of one (1) year of clinical experience with an understanding of clinical experience; or any combination of education and experience, which would provide an equivalent background.
  • Current unrestricted RN or LPN license required.
  • Experience in an acute hospital utilization review and/or case management is required.
  • Previous experience appealing clinical denials for hospitals/physicians preferred.
  • Familiarity with Millman and InterQual guidelines preferred.
  • Proficient in Microsoft Word, Excel, and other desktop software.
    
    Benefits
    
    Aspirion offers a competitive benefit package and workplace perks. Please inquire during the interview process.

Keywords: Aspirion, Raleigh , Clinical Review Nurse - Remote, Healthcare , Raleigh, North Carolina