Clinical Appeals Nurse

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

📋 Description

• Examine medical records and develop clinical appeals in response to medical necessity denials and DRG reassignments.

• Create professional and impactful clinical appeals for managed care, governmental, or RAC denials for hospital clients.

• Apply industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, and best practice standards while reviewing medical records and drafting appeals.

• Engage in telephonic Administrative Law Judge Hearings.

• Deliver oral presentations aimed at reversing Medicare denials.

⛳️ Requirements

• Bachelor of Science degree in Nursing.

• Valid state RN licensure.

• Minimum of 5 years of clinical experience in an acute care environment.

• At least 3 years of experience in case management, concurrent review, or utilization management.

• Expertise in medical record review.

• Excellent written communication abilities.

• Proficiency in Microsoft Word.

• Flexibility to adjust working hours throughout the day based on the training schedule, including occasional evenings and weekends.

• All applicants must possess legal authorization to work in the United States.

• Netsmart does not offer work visa sponsorship for this role.

• Successful completion of a pre-employment background check, including a drug screening, is required.

• Preferred: Experience in payer case management.

🏝️ Benefits

• Equal employment and advancement opportunities.

• Pre-employment background check and drug screening conducted at Netsmart’s expense.

• A healthy and safe workplace.

• Full-time employment.