Appeals Nurse Resume Samples

An Appeals Nurse is a nurse practitioner or registered nurse who helps to increase patient access to care by working with healthcare providers, health insurance companies, and government programs to ensure that series are covered and provided. The job duties often listed on the Appeals Nurse Resume include – providing care coordination, customer service, and advocacy services to ensure that patients get the care they need, gathering medical information, preparing and submitting appeals, creating and maintaining case files, reviewing insurance policies, and providing education to patients and healthcare professionals.

The skills and knowledge required of an Appeals Nurse include excellent communication skills, knowledge of medical terminology, and understanding of healthcare regulations. In addition, these nurses should have the ability to research and analyze data, problem-solve, and think critically. Most employers require that Appeals Nurses have a bachelor’s degree in nursing or a related field. some employers may also require certification or additional licensing.

Appeals Nurse Resume example

Junior Appeals Nurse Resume

Objective : As a Junior Appeals Nurse, responsible for Clarifying, interpreting, and/or evaluating clinical information to assess the appropriateness of current and ongoing restrictions/limitations and level of impairment. Provided coaching and guidance to claim partners regarding medical management. Recommended specific information is needed to evaluate the ongoing level of impairment and to facilitate optimal claim management.

Skills : Strong Attention To Detail; Proficient In Medicare.

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Description :

  1. Combined strong relationship-building skills and clinical knowledge to manage the Authorization and Appeals Management processes.
  2. Investigated and processed appeal requests and authorizations.
  3. Reviewed prospective, retrospective, or concurrent medical records of denied services for medical necessity, as well as processing authorizations. Serves as a liaison with marketing, business office, and administration of the facilities.
  4. Coordinated the managed care determinations and distributes information to the marketing and admissions support staff across multiple markets.
  5. Identified information needed from the referring hospital to finalize the authorization.
  6. Acted as a clinical resource to claim professionals during claim meetings and clinical forums as needed.
  7. Identified pertinent clinical facts and answered questions in collaboration with claims resolution specialists and physician consultants.
                                    Years of Experience
                                    Experience
                                    2-5 Years
                                    Experience Level
                                    Level
                                    Junior
                                    Education
                                    Education
                                    MHA


                                    Clinical Appeals Nurse Resume

                                    Objective : As a Clinical Appeals Nurse, Made appropriate referrals to internal and external clinical resources (i.e., IME, FCE, and Peer Reviews). Identified and recommended process improvements that significantly reduce workloads or improve quality for their assigned area(s) of responsibility.

                                    Skills : Office Suite, Written and Verbal Skills.

                                    Clinical Appeals Nurse Resume Template
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                                    Description :

                                    1. Shared knowledge on the assessment of health issues, work capacity, and return to work opportunities.
                                    2. Consulted/Analyzed more complex assignments and/or projects for their assigned area(s) of responsibility.
                                    3. Discussed medical issues with health care providers as needed to obtain pertinent information and document outcomes of discussions.
                                    4. Championed and enhanced organizational initiatives by positively influencing and supporting change management and/or departmental/enterprise initiatives within assigned area(s) of responsibility.
                                    5. Maintained knowledge of current and emerging developments/trends for assigned area(s) of responsibility, assesses the impact, and collaborates with management to incorporate new trends and developments in current and future solutions.
                                    6. Effectively managed assigned caseload within department productivity goals.
                                    7. Provided and received constructive feedback in a professional manner to/from internal/external customers.
                                                    Years of Experience
                                                    Experience
                                                    0-2 Years
                                                    Experience Level
                                                    Level
                                                    Entry Level
                                                    Education
                                                    Education
                                                    Bachelor Of Science In Nursing


                                                    Hospital Appeals Nurse Resume

                                                    Objective : As a Hospital Appeals Nurse, experience in Writing member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability (including proper grammar, spelling, and punctuation), as well as the ability to follow grade-level requirements. (including, but not limited to DENC letter, IDN letter, Exhaustion of Benefits letter, Administrative Denial letter, and Provider Denial letter). Reviewed NOMNC for validity before processing appeal requests.

                                                    Skills : Leadership, Computer Skills, Documentation Skills.

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                                                    Description :

                                                    1. Ensured timely processing of all denial-related and member-oriented written communications from Navi Health. 
                                                    2. Ensured that all denial information is processed according to protocol and that all documentation is timely and met all Federal and State requirements.
                                                    3. Ensured second-level reviews have been performed and documented and may confer with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICCs), Skilled Inpatient Care Coordinators (SICCs), Pre-service Coordinators (PSCs), and facility personnel in determining denial information is processed timely and appropriately utilizing Navi Health proprietary technology.
                                                    4. Served as a liaison with regard to communicating with internal and external customers, including health plans, providers, members, quality organizations, and other Navi Health colleagues.
                                                    5. Documented and communicated appeal and denial information via fax, email, or through established portal access, including d appeal and denial letters, NOMNC letters, AOR forms, and clinical information.
                                                    6. Acted as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their teams.
                                                    7. Served as a liaison for requests for information from QIO or health plan staff.
                                                                                Years of Experience
                                                                                Experience
                                                                                2-5 Years
                                                                                Experience Level
                                                                                Level
                                                                                Junior
                                                                                Education
                                                                                Education
                                                                                MA In Nursing

                                                                                Appeals Nurse Resume

                                                                                Objective : As an Appeals Nurse, Experience in Sending reviews to Medical Director for rescinding NOMNC when necessary, following Navi Health processes. Coordinated and communicated with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed. Processed Health Plan appeals, IRE appeals, and ALJ appeal notifications and determinations as needed. Followed all established facility policies and procedures.

                                                                                Skills : Documentation Skills, Nursing, Verbal and Written Skills.

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                                                                                Description :

                                                                                1. Researched and analyzed accounts denied for clinical reasons.
                                                                                2. Reviewed medical records to substantiate the clinical rationale to support appeals.
                                                                                3. Utilized InterQual guidelines to support clinical appeals.
                                                                                4. Audited medical records and corrected patient accounts for accurate billing.
                                                                                5. Conducted in-services for case management, physicians, and upper management regarding clinical denial issues.
                                                                                6. Escalated clinical denial issues and trends to upper management for denial prevention and resolution.
                                                                                7. Interacted with the HIM department and CBO staff to resolve coding issues.
                                                                                            Years of Experience
                                                                                            Experience
                                                                                            0-2 Years
                                                                                            Experience Level
                                                                                            Level
                                                                                            Junior
                                                                                            Education
                                                                                            Education
                                                                                            BS In Nursing

                                                                                            Appeals Nurse Resume

                                                                                            Summary : As an Appeals Nurse, Assisted with completing pre-service authorization requests to assist the pre-service team as needed. Participated in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs. Owned assigning appeal requests or determination notifications that are received via fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management. Completed appeal and denial processes in accordance with CMS and Navi Health guidelines and compliance policies.

                                                                                            Skills : Interpersonal Skills, Nursing, and Medical Skills.

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                                                                                            Description :

                                                                                            1. Reviewed all medical documentation and obtain additional clinical information as needed to file appeals to resolve payor denial of reimbursement on inpatient, outpatient, and observation claims.
                                                                                            2. Thorough knowledged of revenue cycle, and medical necessity criteria for inpatient and outpatient services and procedures.
                                                                                            3. Monitored processing systems for patterns and trends in denials.
                                                                                            4. Comfortable documented within multiple computer software systems and EMR simultaneously.
                                                                                            5. Reviewed prospective, inpatient, or retrospective medical records of denied services for medical necessity.
                                                                                            6. Extrapolated and summarized medical information for medical directors, consultants, and other external reviews.
                                                                                            7. Prepared recommendations to either uphold or deny appeals and forwarded them to Medical Director for approval.
                                                                                                                Years of Experience
                                                                                                                Experience
                                                                                                                7-10 Years
                                                                                                                Experience Level
                                                                                                                Level
                                                                                                                Senior
                                                                                                                Education
                                                                                                                Education
                                                                                                                BA In Nursing

                                                                                                                Appeals Nurse Resume

                                                                                                                Summary : As an Appeals Nurse, Expeirnce on Directly interacting with providers to obtain additional clinical information as well as with members or their advocates to understand the full intent of the appeal or grievance. Received an appeal or grievance case, prior to assigning it to the Coordinator Appeals and Grievances. Focused the majority of their time on obtaining appropriate medical records and ensuring the case has a timely, compliant decision.

                                                                                                                Skills : Critical Thinking, Presentational Skills, Written Skills.

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                                                                                                                Description :

                                                                                                                1. Outreached to the appellant on their representative and is responsible for obtaining and reviewing medical records and packaging all pertinent information into a case for a determination.
                                                                                                                2. Reviewed the final determination and created the decision letter which must contain the required information as dictated by regulatory entities and must be mailed on or before compliance time frames.
                                                                                                                3. Utilized InterQual criteria and understand how to apply them to Appeals and Grievances reviews.
                                                                                                                4. Stayed current with department and ACFC policies and procedures.
                                                                                                                5. Maintained familiarity and compliance with federal, state, and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations.
                                                                                                                6. Conducted investigations and reviews of member and provider medical necessity appeals. 
                                                                                                                7. Knowledge of health plan DOFRs and contracts and how they apply to the review process.
                                                                                                                                              Years of Experience
                                                                                                                                              Experience
                                                                                                                                              10+ Years
                                                                                                                                              Experience Level
                                                                                                                                              Level
                                                                                                                                              Management
                                                                                                                                              Education
                                                                                                                                              Education
                                                                                                                                              MHA

                                                                                                                                              Appeals Nurse Resume

                                                                                                                                              Summary : As an Appeals Nurse, Participated in various workgroups for purposes of Continuous Quality Improvement (CQI) to promote consistent medical review of claim documentation and information. Complied with UM policies and procedures. Annual review of UM policies. Reviewed screening incoming service referral requests for medical necessity. Applied the appropriate clinical criteria/guideline, policy, EOC/benefit policy, and clinical judgment to render coverage determination/recommendation for the review process.

                                                                                                                                              Skills : Nursing, Leadership, Strong Letter Writing, Attention to detail.

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                                                                                                                                              Description :

                                                                                                                                              1. Ensured that appeals and grievances are resolved timely to meet regulatory timeframes.
                                                                                                                                              2. Documented and logged appeal/grievance information on relevant tracking systems and mainframe systems.
                                                                                                                                              3. Generated written correspondence to providers, members, and regulatory entities.
                                                                                                                                              4. Utilized leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
                                                                                                                                              5. Interacted with the Director of Managed Care and Provider Relations on managed care contract issues regarding clinical denials.
                                                                                                                                              6. Systematically reviewed medical record claims with denied payment for services rendered, summarized daily service, and support clinical services.
                                                                                                                                              7. Submitted report to the medical director to uphold or overturn denied the claim, and prepared upheld claims for retraction of payment.
                                                                                                                                                  Years of Experience
                                                                                                                                                  Experience
                                                                                                                                                  7-10 Years
                                                                                                                                                  Experience Level
                                                                                                                                                  Level
                                                                                                                                                  Senior
                                                                                                                                                  Education
                                                                                                                                                  Education
                                                                                                                                                  MHA

                                                                                                                                                  Appeals Nurse Resume

                                                                                                                                                  Objective : As an Appeals Nurse, Experience in Providing clear and concise written explanations for reasons a specific claim or set of claims cannot be paid as a result of first-level redetermination. Worked with and provide direction to Redetermination Representatives to assure all redeterminations which require a clinical decision are responded to within CMS quality and timelines standards. Analyzed referrals and identify specific high-volume problem issues and relay information to Redeterminations Manager and Senior Analyst.

                                                                                                                                                  Skills : Understanding of Interpersonal Dynamics, Nursing Care, and Analyzing Skills.

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                                                                                                                                                  Description :

                                                                                                                                                  1. Achieved full adherence to confidentiality and compliance with HIPPA requirements, Milliman and InterQual clinical criteria, and ICD-9.
                                                                                                                                                  2. Provided nursing care to patients within an assigned hospital Unit, Clinic, or any SFDPH setting that requires Registered Nursing care.
                                                                                                                                                  3. Observed and reports symptoms and conditions of patients.
                                                                                                                                                  4. Took and recorded vital signs or other diagnostics including temperatures, respiration, and pulse.
                                                                                                                                                  5. Reported unusual occurrences and unusual results of treatments.
                                                                                                                                                  6. Set up treatment trays, and prepares instruments and other equipment.
                                                                                                                                                  7. Implemented medical and nursing care plans.
                                                                                                                                                                        Years of Experience
                                                                                                                                                                        Experience
                                                                                                                                                                        0-2 Years
                                                                                                                                                                        Experience Level
                                                                                                                                                                        Level
                                                                                                                                                                        Entry Level
                                                                                                                                                                        Education
                                                                                                                                                                        Education
                                                                                                                                                                        MHA

                                                                                                                                                                        Appeals Nurse Resume

                                                                                                                                                                        Objective : As an Appeals Nurse, I Collaborated with healthcare providers to promote the most appropriate, highest quality, and effective use of required tests, medications, interventional procedures, and surgeries to ensure quality member outcomes and to optimize member benefits. Conducted initial medical necessity clinical screenings. Determined if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review by a Medical Director.

                                                                                                                                                                        Skills : Supports Organizational Efforts, Basic Computer Programs, and Collaborative Skills.

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                                                                                                                                                                        Description :

                                                                                                                                                                        1. Directed and supervised the patient care provided by nursing personnel.
                                                                                                                                                                        2. Maintained standard unit or clinic activities.
                                                                                                                                                                        3. Assisted in administering highly specialized therapy.
                                                                                                                                                                        4. Maintained records reflecting patients' condition, medication, treatment, and reactions.
                                                                                                                                                                        5. Followed regulations, policies, and procedures for nursing care.
                                                                                                                                                                        6. May directed the work of auxiliary sub-professional personnel in performing various tasks in assisting with the care and comfort of patients and the cleanliness and sanitation of wards, hospital beds, and appurtenant equipment.
                                                                                                                                                                        7. Received pre-authorization requests from front-line intake and nurse reviewers.
                                                                                                                                                                                                Years of Experience
                                                                                                                                                                                                Experience
                                                                                                                                                                                                2-5 Years
                                                                                                                                                                                                Experience Level
                                                                                                                                                                                                Level
                                                                                                                                                                                                Junior
                                                                                                                                                                                                Education
                                                                                                                                                                                                Education
                                                                                                                                                                                                MA In Nursing

                                                                                                                                                                                                Appeals Nurse Resume

                                                                                                                                                                                                Summary : As an Appeals Nurse, Experience Working closely with Medical Directors to review and make recommendations regarding the medical necessity of requested tests, medications, interventional procedures, and surgeries. Documenting the results of the initial clinical review and determination in the pre-certification system. Conducted initial medical necessity review of out-of-network pre-authorization requests for services. Conducted review of grievance and appeals requests to provide to Medical Directors.

                                                                                                                                                                                                Skills : Medical Skills, Nursing, and Clinical Skills.

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                                                                                                                                                                                                Description :

                                                                                                                                                                                                1. Completed initial screenings for home infusion and hemophilia patients; assist with infusion pump programming and troubleshooting based on a Plan of Treatment (POT) established by a pharmacist.
                                                                                                                                                                                                2. Built an appropriate supply list; completed first refill reviews.
                                                                                                                                                                                                3. Completed disease assessment; provided disease and injection/infusion education; completed assay management activities for Hemophilia patients.
                                                                                                                                                                                                4. Served as Point-of-Contact for disease-specific operations teams.
                                                                                                                                                                                                5. Obtained nursing orders and provide patient clinical nursing management
                                                                                                                                                                                                6. Coordinated home nursing with appropriate contracted agencies and completed follow-up calls to ensure patient satisfaction with home infusion nurse services provided as needed.
                                                                                                                                                                                                7. Utilized clinical knowledge and clinical review judgment to conduct a medical review of claim documentation for first-level appeal cases.
                                                                                                                                                                                                                  Years of Experience
                                                                                                                                                                                                                  Experience
                                                                                                                                                                                                                  7-10 Years
                                                                                                                                                                                                                  Experience Level
                                                                                                                                                                                                                  Level
                                                                                                                                                                                                                  Senior
                                                                                                                                                                                                                  Education
                                                                                                                                                                                                                  Education
                                                                                                                                                                                                                  BA In Nursing