Clinical Appeals Review Nurse

Remote, CA 90802

Industry: Nurse - Compliance/Appeals Job Number: 2501

Clinical Appeals Review Nurse – Managed Resources

Full-Time | Remote| Permanent

Our Clinical Appeals Review services consists of reviewing and appealing for reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase. Denial of payment may be based on insufficient medical record documentation to support level of care, billing/coding disputes, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not Medically Necessary.

Managed Resources is a leading consulting group assisting healthcare organizations nationwide in optimizing its revenue cycle management through review, recovery and educational programs.

Please read the below description and apply if you meet the requirements and would like to hear more about this opportunity with Managed Resources.

DESCRIPTION
  • Writes quality appeal letters to achieve maximum overturn rate
  • Ensure work load is completed in an efficient and timely manner
  • Review cases and determine the potential for a Provide Appeal, on the denied claim
  • Other duties, as assigned

QUALIFICATIONS 

Required:
  • 5+ years of acute hospital experience
  • RN License
  • Possess knowledge and experience with national clinical criteria applied in case management including Interqual and Milliman Care Guidelines
  • Working knowledge of billing codes, revenue codes, CPT’ s, etc.
  • Experience and knowledge of managed care contracts, account receivables, and revenue cycle functions
  • Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry based standards
  • Experience and success in appealing managed care denials and underpayment decisions
  • Ability to examine financial and clinical data trends and provide recommended action steps to resolve

Preferred:
  • Certification in Case Management, Legal Nurse Consulting, or Coding is a plus
  • Experience with case management software such as Midas is preferred

Managed Resources is an Equal Opportunity Employer (EOE) M/F/D/V/SO

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