Clinical Appeals Nurse (RN) - Remote

Overview

The Clinical Appeals Nurse is responsible for making appropriate clinical decisions regarding appeals outcomes, ensuring compliance with standards while supporting the Claims business.

In Short

• Conducts clinical/medical reviews of denied claims.
• Ensures medical necessity and accurate billing.
• Identifies quality of care issues.
• Assists with complex claim reviews.
• Documents findings in the database.
• Provides training and support to clinical staff.
• Represents the organization in hearings.
• Applies advanced clinical knowledge for decision making.
• Collaborates with Chief Medical Officer on denial decisions.
• Maintains knowledge of healthcare regulations.

Requirements

• Graduate from an Accredited School of Nursing.
• Active, unrestricted RN license.
• 3-5 years of clinical nursing experience.
• Knowledge of ICD-9, CPT coding, and CMS guidelines.
• Experience in Managed Care or related fields.
• Ability to interpret healthcare regulations.
• Preferred Bachelor's Degree in Nursing.
• Preferred certifications in healthcare management.

Benefits

• Competitive benefits and compensation package.
• Equal Opportunity Employer.