Clinical Nurse Specialist

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

📋 Description

• Review and evaluate medical records along with denial rationales to create clinically substantiated appeal arguments.

• Analyze and implement clinical guidelines (such as InterQual, Milliman) to substantiate determinations of medical necessity.

• Prepare, revise, and enhance appeals utilizing internal tools (for example, DOCIQ).

• Precisely identify denial root causes and complete nurse review reporting.

• Detect denial trends and communicate insights to aid in prevention strategies and process improvements.

• Clearly document all case activities within internal and client systems.

• Engage in quality control assessments and offer feedback to enhance the effectiveness of appeals.

• Work collaboratively with operations and leadership to fulfill client expectations and achieve performance targets.

⛳️ Requirements

• Current LPN or RN license (mandatory).

• A minimum of 1 year of experience in utilization review, case management, or clinical denials.

• At least 1 year of experience in resolving hospital clinical denials.

• Strong clinical reasoning and critical thinking abilities.

• Competence in interpreting medical documentation and payer guidelines.

• Familiarity with utilization management and medical necessity criteria (such as InterQual, Milliman).

• Excellent written communication skills for crafting persuasive clinical appeals.

• Attention to detail with the capacity to manage multiple priorities effectively.

• Proficient in using EMRs and healthcare systems.

🏝️ Benefits

• Health insurance.

• 401(k) matching.

• Flexible working hours.

• Paid time off.

• Professional development opportunities.