Contract only - 3 Months+ (Potential for extension)
Onsite position - Must be a local candidate
Virtual Teams interview with Hiring Manager, Jason Perla
Start date - currently listed for 11/30 *Would need to clear by 11/23 for 11/30 start due to holiday or be pushed to 12/7 start date
Schedule - Monday-Friday, typically 8am-5pm (Some flexibility for an earlier start/end time)
Training - "One on One" | On-the-job
Must-have qualifications:
- 3 years of clinical experience; or 2 years of clinical experience plus 1 year of utilization/medical review, quality assurance, or home health experience
- Associate Degree in Nursing or graduate of an accredited School of Nursing
- Active, unrestricted RN license in the state of hire or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
- Healthcare insurance experience preferred
Day-to-day work will focus heavily on reviewing medical records and provider appeals/denials, confirming appropriate coding, and determining whether a denial should be upheld or overturned.
Please ensure candidates are genuinely interested in an appeals/clinical review role and understand this is not a traditional bedside RN position before submitting.
Please confirm the candidate meets the required RN licensure and experience requirements listed above before submission.
Manager is specifically looking for candidates who demonstrate dependability and accountability.
Due to onboarding timelines, please submit candidates who are responsive and able to move quickly through interview and screening.
Duties:- Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment, medical and pharmacy review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested. services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.
- Job Description: Documents the basis of the appeal or retrospective review in an accurate and timely manner and accordance with regulations or standards. Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements. governing agencies, policies, authorizations and procedures while adhering to confidentiality regulations regarding protected health information. Performs appeal and retrospective reviews demonstrating the ability to define and determine the precedence of pertinent issues in applying policies and procedures to clinical information and or application to benefit or policy provisions. Performs special projects, including reviews of clinical information to identify the quality-of-care issues. null
Skills:
Required work experience: 3 years of clinical or 2 years of clinical experience plus 1 year utilization/medical review, quality assurance, and home health experience. Preferred: Healthcare insurance experience. null