Clinical Appeals Specialists
Lifespan Corporate Services - Providence, RI

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Description : The Clinical Appeals Specialist reports to the Manager Appeals. Under general supervision and within Lifespan policies and procedures, works collaboratively with The Miriam Hospital and Rhode Island Hospital and multiple system-wide departments. Is responsible for review of medical records to ascertain appeal information and for the development of appeal correspondence. Analyzes clinical denials based on severity of illness and intensity of service using InterQual criteria and Center for Medicare and Medicaid Services (CMS) guidelines. Analyzes and reports data of audits at the facility and system-wide level. Provides education to Lifespan staff and physicians to reduce future audit exposure.
Qualifications : Must have current licensure to practice as a Registered Nurse in the State of Rhode Island or in another state that participates in the Nurse Licensure Compact. Bachelor’s Degree in Nursing, Health Science or Health Business required, Master’s Degree preferred. Three years or more of relevant recent clinical and/or administrative experience in medical/surgical nursing; two years of which must be related to utilization review activities, demonstrating organizational skills and ability to make sound clinical judgment. Working knowledge of level of care criteria is required. Knowledge of state and federal regulations is desirable.

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