Clinical Appeals RN

Overview

The Appeals Nurse will review medical records to construct compelling clinical appeals in order to overturn managed care denials based upon clinical nursing judgment and the medical necessity of services delivered.

• Review of medical records to evaluate the validity of 3rd party denials.
• Assess strength of completed appeal to predict favorable outcomes.
• Ability to detect issues resulting in denials and constructively report on issue to assist in resolution.
• Construct 1st and 2nd level appeals by applying clinical rationale.
• Manage assigned workload of accounts so appeals are submitted timely in accordance with payer time frames.

• Licensed RN.
• 5 years experience working in acute hospital setting.
• Knowledge of managed care and utilization review process.
• Knowledge of Interqual criteria and/or Milliman Guidelines.
• Knowledge of DRGs.
• Excellent written skills.
• Proficient computer skills including Microsoft Office, with access to high-speed internet.
• Experience as a Case Manager or UR nurse who has written appeals is required.

This role does not offer an hourly rate. Payment is a 1099 paid bi-weekly upon Reviews. We will pay $50 per Appeal, and $25 per Review if cannot be appealed. You will also be paid $25/hour for any IT/ Compliance trainings that require completion of your time.

All your information will be kept confidential according to EEO guidelines.

During employment, employees are treated without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status.

At times, government agencies require periodic reports from employers on the sex, ethnicity, handicap, veteran and other protected status of employees. The purpose of this Administrative EEO Record is for statistical analysis only and is used to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of the Administrative EEO record is optional.

If you choose to volunteer the requested information, please note that all Administrative EEO Records are kept in a Confidential File and are not part of your Application for Employment or Personnel file.

Please note:

YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.