Clinical Appeals Nurse, PRN

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

📋 Description

• Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients.

• Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to bolster appeal arguments.

• Engage in Administrative Law Judge (ALJ) Hearings and present oral arguments advocating for the reversal of Medicare denials.

• Analyze patterns of denial and provide insights to help minimize future occurrences.

• Work collaboratively with the appeals team and hospital clients regarding the status and outcomes of appeals.

• Stay updated on healthcare regulations, coding guidelines, and payer policies pertinent to the appeals process.

⛳️ Requirements

• Bachelor's of Science in Nursing (BSN) or an equivalent degree.

• Current and unrestricted RN license.

• A minimum of 5 years of clinical experience in acute care settings.

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

• Outstanding written and verbal communication abilities.

• Proficient in the MS Office suite, especially Word and Excel.

• Strong analytical and problem-solving skills with a keen attention to detail.

• 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 screen, is required.

• Preferred: Experience in payer-side case management or medical director-level review.

🏝️ Benefits

• Part-time employment.

• Remote work options.

• Virtual collaboration tools.

• Occasional travel for conferences, client meetings, or in-person hearings.

• Pre-employment background check and drug screen are covered at Netsmart’s expense.