CLINICAL APPEALS RN SKILLS, EXPERIENCE, AND JOB REQUIREMENTS
The Clinical Appeals Registered Nurse with clinical experience in autoimmune, primary immune, and inflammatory diseases is proficient in Microsoft Office and SharePoint. This role requires familiarity with clinical documentation, telephonic patient assessments, home infusion procedures, and specialty infusions like IVIG and Remicade. Additionally, the nurse should have expertise in prior authorization, utilization review, appeals, health insurance languages, payer reimbursements, and government payment systems such as Medicare and Medicaid.
Essential Hard and Soft Skills for a Standout Clinical Appeals RN Resume
- Medical Coding
- Clinical Documentation Improvement
- Legal And Regulatory Compliance
- Knowledge Of Payer Policies
- Case Management Software Proficiency
- Electronic Health Record Systems
- Data Analysis
- Pharmacology
- Medical Terminology
- Health Information Technology
- Analytical Thinking
- Attention To Detail
- Persuasive Communication
- Negotiation
- Problem-Solving
- Empathy
- Adaptability
- Team Collaboration
- Stress Management
- Ethical Judgment
Summary of Clinical Appeals RN Knowledge and Qualifications on Resume
1. BS in Nursing with 3 years of Experience
- Have an unrestricted, active RN license
- Proven RN working experience in the acute setting
- Working knowledge of Clinical Criteria and CMS Guidelines
- Proficient in Basic Computer Skills
- Ability to have high-speed internet installed in the home for Secure Job use only
- Designated HIPPA-compliant home workspace
- Utilization management, prior authorization, case management, or prior appeals experience
- Experience working with claims and coding
- Strong interpersonal, verbal and written communication skills
2. BS in Health Information Management with 2 years of Experience
- Current active unrestricted Massachusetts RN license.
- Nursing experience in a Managed Care setting
- Working experience in clinical nursing
- Experience in Medicaid/Medicare grievances and appeals and/or Utilization Review
- Strong oral, written and interpersonal communication skills
- Excellent problem-solving and analytical Skills
- Proficiency in Microsoft Word, Excel and Outlook.
- Ability to work independently and make decision
- Comfort working in a team-based environment
- Working knowledge of and ability to navigate through the healthcare system
3. BS in Healthcare Administration with 5 years of Experience
- Have a Licensed Registered Nurse (RN) in the state of residence
- Clinical working experience as a Registered Nurse
- Experience in autoimmune, primary immune, and/or inflammatory disease states
- Understanding of clinical documentation from physician offices and telephonic assessment notes of patients
- Proficiency with Microsoft Word, Excel, and SharePoint
- Home Infusion working experience
- Knowledge of specialty infusions such as IVIG and Remicade
- Advanced computer skills with experience in a paperless role
- Prior authorization, pre-certification, utilization review, and/or appeals experience
- Understanding of health insurance summary plan description language
- Understanding of how payer reimbursements work, plus co-pays, co-insurance, and deductibles
- Understanding of government payment systems such as Medicare and Medicaid
Relevant Information