Clinical Appeals & Grievances Nurse Reviewer

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

📋 Description

• Evaluate medical records and case documents concerning intricate Medicare appeals and disputes.

• Compose clear, concise, and unbiased reconsideration and dispute-resolution decisions that are backed by medical evidence and policy.

• Make autonomous decisions based on medical evidence, statutes, regulations, rulings, policies, procedures, and relevant guidelines.

• Address all appeal and dispute matters raised by beneficiaries/patients, their representatives, and providers/suppliers.

• Investigate federal regulations, contract policies, medical-practice standards, manuals, coverage-issues manuals, medical literature, and related resources.

• Keep abreast of changes in regulatory, medical, healthcare-practice, policy, and procedural areas.

• Engage in case-specific verbal discussions.

• Review appeals and disputes that involve multiple beneficiaries or services within a single case.

• Strategize responses to statistical-analysis challenges with support from statisticians.

• Attend meetings and contribute to management-directed workgroups.

• Act as a subject matter expert.

• Mentor and/or train staff members.

• Conduct quality reviews and audits as necessary.

• Participate in special projects and carry out other assigned responsibilities.

⛳️ Requirements

• A minimum of 3 years of experience in medical dispute resolution, Medicare appeals, medical review, clinical review, or a related healthcare field.

• An active, unrestricted Nurse license in good standing; licenses that have restrictions or encumbrances are not eligible.

• Proven experience in writing or making appeal or payment determinations.

• Proficient in using Microsoft 365, including Excel and Word.

• Must successfully pass Federal and state criminal background checks, as required by the client.

• Must successfully pass education, certification, and license verification along with other professional background checks, as required by the client.

• Must pass a drug screening, as required by the client.

• Must be legally authorized to work in the United States without employer sponsorship, both now and in the future.

• Preferred: experience with medical necessity determinations, payments, and billing/claims.

• Preferred: experience in supporting a federal public health agency environment.

• Preferred: experience in Patient-Provider Dispute Resolution or Independent Dispute Resolution.

• Preferred: coding certification.

• Must be an actively licensed healthcare professional with experience in nursing, physical therapy, respiratory therapy, occupational therapy, or a closely related clinical field.

• Must work during Eastern, Central, or Mountain Time Zone business hours and be available for rotating weekend and holiday schedules.

• Prolonged periods of sitting at a desk and working on a computer are required.

• May occasionally be required to lift up to 25 pounds.

🏝️ Benefits

• Fully remote position.

• Opportunity to support a federal client.

• Involvement in special projects, workgroups, and professional activities.

• Mentoring and/or training opportunities.