Nurse Reviewer – Appeals and Hearing

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

📋 Description

• Oversee and execute all responsibilities related to appeals.

• Evaluate and respond appropriately to provider appeals.

• Review documentation to guarantee that all elements of appeals are accurately and thoroughly addressed.

• Assess provider appeals and redeterminations in accordance with sanctioned clinical and coding guidelines.

• Clearly and concisely document appeal decisions.

• Compile case files and summaries for hearings.

• Actively engage in both virtual and in-person hearings alongside the Medical Director.

• Support management in training new reviewers through daily oversight, mentorship, feedback, and educational initiatives.

• Keep up-to-date with current clinical criteria and/or coding guidelines.

• Participate in training sessions and scheduled meetings to improve understanding of clinical policies, procedures, rules, and regulations.

• Train across various claim types to address client needs effectively.

⛳️ Requirements

• A valid, unrestricted RN license in the United States.

• If applicable, a valid multistate RN license under the Nurse Licensure Compact (NLC).

• A minimum of 5 years of clinical experience or medical record coding expertise.

• At least 3 years of experience in utilization review or claims auditing.

• Proficient understanding of the appeals and hearings process.

• Experience in applying clinical review criteria.

• Familiarity with MCG or InterQual is preferred.

• Excellent written and verbal communication abilities.

• Skill in developing clear, fact-based rationales for appeals.

• Capability to present case summaries and decisions effectively.

• Ability to handle multiple priorities in a dynamic work environment.

• Willingness to attend training and scheduled meetings.

• Capacity to successfully complete necessary CEUs to maintain RN license and/or coding certification.

🏝️ Benefits

• Flexible working hours.

• Work-life balance.

• Opportunities for career development.

• Flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Access to leadership and technical development academies.

• Up to 25% travel for onsite hearing testimony.