Dohmen Life Science Services

  • Clinical Appeals Nurse

    Job Locations US-MO-Chesterfield
    Job ID
    # of Openings
    Customer & Client Services
  • Overview

    Our Culture:

    At Dohmen, we are committed to keeping our clients for life, ensuring no conflict of interest exists, achieving continuous innovation, and focusing on continuous improvement.  Our behavior is guided by five simple values that define how we work and are the essence of what makes us successful:


    Caring: We are empathetic and respectful.  We ask “How can I help you?”

    Committed: We are dedicated and persistent.  We ask “How can I make it happen?”

    Creative: We are inventive and imaginative. We ask “How can I do it better?”

    Collaborative: We are cooperative and share our knowledge. We ask “How can we achieve success?”

    Courageous: We’re willing to risk failure over inaction. We ask “How can I challenge myself”


    The Position:

    The Clinical Appeals Nurse is responsible for managing medical denials by conducting a comprehensive review of clinical documentation to determine if medical necessity criteria are met.  Where an appeal is warranted, the Clinical Appeals Nurse consults with healthcare providers, patients and the medical record to compose sound, compelling, factual arguments for submission.  They manage the appeals process within prescribed timeframes in order to meet the operational goals of the department. Attendance at Administrative Law Judge Hearings may be required.


    Critical Responsibilities:

    • Successfully manage the appeals process from beginning to end within the designated timeframe
    • Ensure appropriate communication through the process with patient, insurance company and internal business partners 

    Essential Duties and Responsibilities:

    • Determine why cases are denied and if an appeal is warranted using knowledge of payer requirements with medical chart data
    • Utilize pre-existing criteria, clinical evidence and other resources as needed to develop sound and well-supported appeal arguments
    • Generate appropriate appeal resolution communication to the member and provider in accordance with company policies
    • Request additional information from providers, as appropriate, to facilitate timely appeals
    • Gather and prepare case information for participation in Administrative Law hearings
    • Summarize and present appeal outcomes to clients and participate in client meetings as needed
    • Review documentation related and level of care decisions with clients
    • Ensure compliance with HIPAA regulations, to include confidentiality, as required
    • All other duties as assigned


    Minimum Qualifications:

    The requirements listed below are representative of the experience, education, knowledge, skill and/or abilities required.

    • Bachelor’s Degree in Nursing
    • Current MO RN license in good standing
    • 4 years’ experience as a clinical nurse in an acute care setting
    • Knowledge of third party payer regulations related to utilization and quality review
    • Analytical, creative, and interpersonal skills essential
    • Excellent communication (written, verbal, and presentation) skills
    • Strong clinical and regulatory knowledge and skills as well as knowledge of payer requirements
    • Strong organizational skills
    • Demonstrated sense of urgency to drive to successful outcomes within the minimum required time frames


    Preferred Qualifications:

    • 2 years’ experience in case management, discharge planning, and/or utilization review
    • Experience with infusion and home health services as well as managed care
    • Experience working with patient consumers with rare chronic disorders
    • Exhibits an upbeat attitude, a genuine interest in others and a sense of humor. Energizes others and heightens morale through her/his attitude
    • Commitment to teamwork
    • Creates a climate that motivates and encourages others to participate
    • Transforms creative ideas into original solutions that positively impact the company’s performance
    • Proves to be a professional of unquestionable integrity, credibility and character who demonstrates high moral and ethical behavior


    Physical AND Mental Demands:

    This is a largely sedentary role.  While performing the duties of this job, the employee is regularly required to talk, hear, type and engage in repetitive motion. 


    The employee frequently is required to walk; use hands to finger, handle or feel; and reach with hands and arms.  The employee is occasionally required to stand or grasp. The employee is intermittently required to stoop or crouch; push or pull; or kneel. 


    The employee must occasionally lift and/or move up to 10 pounds and intermittently lift and/or move up to 25 pounds.  Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.


    This role requires mental alertness. The employee must regularly communicate both verbally and written; concentrate on tasks; and remember and observe details. The employee must frequently adjust to changes; handle stress and emotions; and think analytically.


    The mental and physical requirements described here are representative of those that must be met by an individual to successfully perform the essential functions of this position.


    Working Environment:

    This job operates in a professional office environment. This role routinely uses standard office equipment. The noise level in the work environment is usually moderate.  The employee is not substantially exposed to environmental conditions.


    The work environment characteristics described here are representative of those an individual encounters while performing the essential functions of this position.



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