Clinical Appeals Nurse, PRN

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

📋 Description

• Evaluate medical records and formulate clinical appeals in response to denials related to medical necessity and diagnosis-related group (DRG) reassignments.

• Draft and submit clinical appeals addressing denials from managed care organizations, governmental bodies, and Recovery Audit Contractors (RACs) for hospital clients.

• Examine medical records and apply industry standards, Medicare regulations, and best practice guidelines to bolster appeal arguments.

• Engage in Administrative Law Judge (ALJ) Hearings and deliver oral presentations to advocate for the reversal of Medicare denials.

• Assess denial trends and provide insights aimed at minimizing future denials.

• Work closely with the appeals team and hospital clients to keep them informed on the status and outcomes of appeals.

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

⛳️ Requirements

• Bachelor of Science in Nursing (BSN) or an equivalent qualification.

• Active and unrestricted RN license.

• Minimum of 5 years of clinical experience in acute care environments.

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

• Outstanding written and verbal communication abilities.

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

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

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

• Comfortable with remote work settings and virtual collaboration tools.

• Must be legally authorized to work in the United States.

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

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

🏝️ Benefits

• Part-time employment.

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

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