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