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Appeals Specialist - Licensed RN

Company: Overlake Medical Center
Location: Bellevue
Posted on: July 13, 2018

Job Description:

Overlake Medical Center and clinic is seeking a full time Appeals Specialist. This position is responsible for the coordination of all procedural and substantive elements relating to the Centers for Medicare & Medicaid (CMS) Recovery Audit Contractor (RAC) program, commercial payer audits and charge capture auditing. Including responsibilities such as: prepare any activities pertaining to audits performed by a RAC vendor or other payer i.e., prepayment reviews, post payment denials, etc.; address clinical payment denials and intervene to maximize reimbursement for the services rendered by the hospital; serve as a clinical expert on medical necessity criteria, inpatient/observation criteria, and emergency services criteria; Prepare defense audits for accounts where a payer has identified discrepancies; review charges originally billed against necessary clinical documentation to identify possible under/over charges; communicate any charge findings to compliance and/or the department manager for follow up; and maintain communication with external auditors; review and analyze audit reports/RAC findings, investigate trends, and assist facilities in development and completion of plans to influence improvement.

Benefits Highlights

  • Free public transportation pass (ORCA
  • Professional development
  • Competitive compensation package
  • Generous PTO
  • Medical, dental, vision
  • 2 part retirement plan including matching
  • Long term disability
  • Flex spending
  • Extended illness banked hours
  • Free garage parking
  • Employee Assistance program


    • Associates degree in nursing required. Bachelors degree preferred.
    • Current licensure as a Registered Nurse in the State of Washington is required.
    • Minimum of five (5) years acute care nursing experience required.
    • Prior utilization management, case management, compliance, or payer experience preferred. Healthcare security experience preferred.
    • Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes is required.
    • Working knowledge of Case Management, Discharge Planning, Appeals Management, Clinical Documentation Improvement, and/or Utilization Review preferred.
    • Working knowledge of Medicare reimbursement system and coding structures preferred.
    • Basic knowledge of CPT Codes, ICD9, ICD10, MSDRGs, HCPCs, and/or Standardized level of care status guidebooks preferred.
    • Excellent interpersonal and communication skills to build effective partnering relationships, relating both tactfully and professionally with individuals at all levels of the organization.
    • Demonstrated ability to analyze data with a strong attention to detail is required.
    • Computer literacy and familiarity with the operation of basic office equipment.

      Just a few of our employee perks

      • Cell phone plan discounts
      • Discounted Mariners and Sounders tickets
      • Computer discounts
      • Discounted lift tickets
      • Discounted movie tickets
      • Discounted gym memberships
      • Free Seattle Art Museum passes
      • And much more

        Overlake communityAt Overlake, we believe exceptional patient care comes naturally when our staff feels respected, valued, and cared for. So we've cultivated a culture that feels like a community. In fact, we're more like a great big family. Our people will always be there for you. Our supportive environment and team of passionate professionals have earned the hospital its reputation as a healthcare leader in the region. We are truly committed to providing compassionate, high-quality patient care in a progressive and collaborative environment.

        Overlake Medical Center is an Equal Opportunity Employer

        Keywords: Overlake Medical Center, Seattle, Appeals Specialist - Licensed RN, Healthcare, Bellevue, Washington

        Click here to apply!

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