Clinical Nurse Appeal Analyst Job at Exact Sciences (Madison)

Job Description

The Clinical Nurse Appeal Analyst is responsible for reviewing, analyzing, and responding to clinical denials from payers. This role serves as a critical liaison between clinical departments and the Revenue Cycle Team, ensuring that appeals are supported by appropriate clinical documentation and medical necessity. The ideal candidate will have a strong clinical background, excellent analytical skills, a deep understanding of payer policies, and utilization of review criteria as well as creating strong appeal letters.

Job Responsibility

Review payer denials related to medical necessity, level of care, and clinical documentation
Analyze patient medical records to determine the appropriateness of care and services provided
Draft and submit timely, evidence-based clinical appeals to payers
Collaborate with physicians, case management, and coding teams to gather supporting documentation when needed
Monitor appeal outcomes and identify trends in denials to inform process improvements
Maintain up-to-date knowledge of payer guidelines, CMS regulations, and industry best practices
Educate revenue cycle and non-clinical staff on denial trends and documentation of improvement opportunities
Educate and support non-clinical staff on how to interpret medical policies and draft compelling arguments to overturn denials
Support clinical appeal strategy
Participate in denial management meetings and performance improvement initiatives
Uphold company mission and values through accountability, innovation, integrity, quality, and teamwork
Support and comply with the company’s Quality Management System policies and procedures
Maintain regular and reliable attendance
Ability to act with an inclusion mindset and model these behaviors for the organization
Ability to work designated schedule
Ability to work overtime, as needed
Ability to work on a mobile device, tablet, or in front of a computer screen and/or perform typing for approximately 100% of a typical working day
Ability to work on a computer and phone simultaneously
Ability to use a telephone through a headset
Ability to work seated for approximately 100% of a typical working day
You will be required to successfully complete an assessment showing understanding of Exact Sciences Epic processes necessary to the job functions with a score of 80% or higher

Requirements

Associates Degree in Nursing
3+ years of experience in clinical appeals, utilization review, or case management
Ability to work independently and manage multiple priorities
Familiarity with payer guidelines and medical necessity standards
Possession of active RN license at time of hire and maintain throughout employment in position
Demonstrated ability to perform the essential duties of the position with or without accommodation
Applicants must be currently authorized to work in country where work will be performed on a full or part-time basis

Nice to have

Strong clinical judgment and critical thinking
Excellent written and verbal communication skills
Proficiency in EMR systems and denial management tools
Advanced computer skills to include internet navigation and email usage
Strong in Microsoft Office programs, such as: Word, Excel, Outlook, OneNote, and SharePoint

What we offer

Paid time off (including days for vacation, holidays, volunteering, and personal time)
Paid leave for parents and caregivers
A retirement savings plan
Wellness support
Health benefits including medical, prescription drug, dental, and vision coverage
Bonus eligibility

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Clinical Nurse Appeal Analyst

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