The Medicare Appeals Reviewer works collaboratively with Ministry facilities, patient financial services, and hospital coding and compliance departments. The Appeals Reviewer is responsible for the review of medical records to ascertain appeal information. This person will be responsible for initial development of appeals correspondence materials utilizing Ministry template. Analyzes clinical denials based on severity of illness and intensity of service InterQual criteria, coding guidelines, and CMS guidelines. The Medicare Appeals Reviewer will be responsible for putting together the overall appeal to Medicare in order to receive payment for services rendered.

Essential Duties

• Remains current in Medicare audit timelines.
• Demonstrates competency in application of inpatient admission and continued stay criteria.
• Demonstrates competency in the application of inpatient admission and continued stay criteria in the appeal of inpatient medical necessity denials.
• Demonstrates professional verbal and written communication skills.
• Works collaboratively with various departments in the interest of favorable financial outcomes related to audits.
• Provides feedback loop into documentation in medical record that would reduce audit exposure.
• Responsible to follow system policy/procedure for audit process.
• Demonstrates accurate and timely clinical record review.
• Assembles all appeal correspondence relative to necessary and appropriate documentation.
• Works effectively with other facility's case management, patient finance, and HIM departments for purposes of clarification and/or additional information as required.

This position will require someone who has great attention to detail, good organizational skills and is able to complete tasks on time.

This is an exempt position that will normally work forty hours per week on day shift.  There are no weekends or holidays required for this position.

• Bachelor's degree in nursing is required.
• 3-5 years experience as professional nurse is required.
• 1-2 years utilization management/case management experience preferred.  InterQual experience preferred. 
• Current Registered Nurse licensure in State of Wisconsin.
• Proven ability to work independently with demonstrated good judgment and problem solving skills.
• Effective interpersonal, professional communication and computer skills are required. Basic knowledge of DRG based payment. 
• A Fine attention to detail is required for this position.