RN - Clinical Appeals - Denial Prevention Department Job

Children's Health - Managed Care Careers

Job Number: 54612

Location: Dallas, TX

Date Posted: 6-25-2018



This position is responsible to: writing clinical appeals, audit patient medical and billing records to determine that
documentation and items billing are appropriate; represent Children's in external billing audits with payors; and identify potential billing, charging or documentation issues. This is accomplished by: auditing patient medical and billing records; and completing and finalizing audit results with external payor auditors. Expected results include: overturning clinical denials through the appeals process, accurate completion of audits in a timely manner; follow through to ensure that audit adjustments are made and corrective actions are taken to address identified billing, charging, and documentation issues; and represent Children's in a competent and professional manner with
external clinical auditors.


  • Requires depth within a specialized, critical discipline and/or breadth of substantive professional knowledge that crosses disciplines within the professional field.
  • Interprets internal/external business challenges and recommends best practices to improve products, processes or services
  • Impacts the achievement of customer, operational, project or service objectives.
  • Works independently, with guidance in only the most complex situations
  • Communicates difficult concepts and negotiates with others to adopt a different point of view


  • Review patient medical and billing records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
  • Read and interpret patient medical records to determine that all items billed were documented and that all care documented was correctly billed to the patient. Report audit findings in agreed upon format.
  • Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.
  • Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments.
  • Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
  • Conduct other audits as assigned.
  • Follow up on audit findings to determine that necessary adjustments have been made.
  • Interact as appropriate with all external auditors, internal customers and hospital departments.



  • Five years Significant experience in the healthcare field and managed care organization (MCO) including a minimum of five years as a clinical nurse in an acute care setting is required.
  • Three years experience in case management, discharge planning, other clinical audit function, and/or utilization review is preferred.
  • Five years knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by auditors. Ability to critically evaluate and make decisions about whether appeals should be made based on reviews of patient medical records
  • Two years of EPIC experience.
  • Knowledge in areas such as InterQual Level of Care Criteria and Milliman Care Guidelines
    as well as knowledge of third party payer regulations related to utilization and quality review


  • Bachelor of Science Degree in Nursing is preferred.


  • Unrestricted RN license for State of Texas is required.

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