Clinical Review Nurse
New
T
Ternium Revenue Cycle ManagementHealthcare Revenue
Work from anywhere in the U.S.Full-TimeMiddle
Salary65,000 - 85,000 USD per year
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Job Details
- Experience
- 5+ years
Requirements
- RN License
- 5+ years of acute hospital experience
- Knowledge and experience with national clinical criteria applied in case management including InterQual and Milliman standards
- Experience and knowledge of managed care contracts, account receivables and revenue cycle functions (preferred)
- Experience and success in medical record chart review and appealing managed care denials (preferred)
- Certification in Case Management, Legal Nurse Consulting, or Coding is a plus
Responsibilities
- Analyze denied insurance claims and complete medical records.
- Apply clinical reasoning, national criteria (InterQual/Milliman), and best practices to determine if appeals are justified.
- Draft persuasive, medically sound appeal letters that clearly support the need for treatment or services.
- Collaborate with our legal team to ensure appeals are compelling and complete.
- Stay informed on healthcare regulations, payer trends, and clinical updates.
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