Appeals Nurse Consultant

This is a fully remote position, open to applicants in Connecticut.

📋 Description

• Gather and investigate submitted clinical information from providers to aid in case review and determination processes.

• Analyze documentation to pinpoint relevant clinical aspects and implement CMS guidelines, regulatory standards, and supplemental policies.

• Craft detailed nurse summaries for evaluation by the medical director or finalize appeal decisions utilizing pre-approved workflows.

• Navigate various computer systems and applications to ensure cases are processed accurately, in compliance, and punctually.

• Collaborate with administrative coordinators, clinical nurse consultants, Medical Directors, Project Management, Medicare Appeals Analysts, Data Science, and other departments.

• Assess UM outpatient appeals concerning denied procedures, imaging, and medications that necessitate prior authorization.

• Evaluate UM inpatient appeals related to hospital stays, readmissions, behavioral health, skilled nursing, acute rehabilitation, and long-term acute care.

• Review down-coded claims and DRG assignments utilizing medical records, coding guidelines, and clinical guidelines.

• Analyze coding appeals for denied claims and offer evidence-based recommendations.

• Conduct MPO clinical reviews for claim denials, including CCR and SIU cases.

• Operate autonomously in a virtual team setting while performing sedentary computer-based tasks, data entry, typing, and utilizing standardized templates.

⛳️ Requirements

• 3-5 years of experience as a Registered Nurse.

• At least 3+ years of clinical or hospital nursing experience.

• A Registered Nurse associate’s degree or Diploma RN is required.

• An active RN State License is required.

• Over 1 year of experience in Medicare Utilization Management, case review, or prior authorization is preferred.

• Experience in Utilization Management, Managed Care, or Appeals is preferred.

• Coding experience is preferred.

• Prior Authorization experience is preferred.

• Capability to apply CMS guidelines, regulatory requirements, and relevant supplemental policies.

• Clinical expertise and the ability to consistently implement clinical and regulatory standards in decision-making.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• CVS Health bonus, commission, or short-term incentive program in addition to base pay.