Nurse Reviewer Appeals and Hearings
New
Remote within the U.S.Full-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 5+ years of clinical experience or 5+ years of medical record coding experience; 3+ years of utilization review experience or claims auditing.
Requirements
- Active, unrestricted RN license in the United States.
- Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
- 5+ years of clinical experience or 5+ years of medical record coding experience.
- 3+ years of utilization review experience or claims auditing.
- Working knowledge of the appeals and hearings process.
- Experience using MCG or InterQual criteria preferred.
- Excellent written communication skills for writing clear, concise, and fact-based rationales.
- Excellent oral communication skills for presenting case summaries and decisions.
- Ability to multi-task in a fast-paced production environment.
- Commitment to completing required CEUs to maintain licensure and/or certification.
Responsibilities
- Review provider appeals and redeterminations using approved clinical and coding guidelines.
- Analyze and review appeal documentation to ensure accuracy and adherence to production goals.
- Prepare case files and case summaries for hearings.
- Participate in virtual and on-site hearings in conjunction with the Medical Director.
- Assist management with training, mentoring, and educating new reviewers.
- Attend training and meetings to maintain knowledge of clinical policies and regulations.
- Cross-train to perform reviews of multiple claim types.
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