This is a fully remote position, open to applicants in Alabama, +18 more states.

📋 Description

• Evaluate medical record documentation to confirm issues related to medical necessity, including length of stay, level of care, readmissions, experimental/investigational services, and similar concerns.

• Develop comprehensive clinical analyses and appeal letters for payer denials to facilitate the payment of patient claims.

• Oversee inventory and follow up on accounts as necessary.

• Assess InterQual/Milliman and/or payer medical policies concerning denied procedures or services and incorporate relevant criteria into analyses and appeal letters as needed.

• Offer constructive feedback to the supervisor on issues identified for the ongoing training of peers and non-clinical staff.

• Recognize root causes and trends to communicate with clients and staff.

• Collaborate with attorneys and claims representatives to review and appeal claims when suitable to reverse clinical denials from Medicare, Medicaid, and other third-party payers.

⛳️ Requirements

• Current RN license required.

• Minimum of 2 years of experience in an acute care hospital is necessary.

• Preferred experience of three to five years in utilization review, case management, quality assurance, discharge planning, or other cost management programs.

• Familiarity with InterQual and Milliman healthcare criteria is preferred.

• Experience in reviewing CMS LCD/NCD criteria is preferred.

• Essential proficiency in typing and computer skills.

• Valid government-issued photo ID required during screening and/or interviews.

• Applicants from the following states will be given priority: Alabama, Arkansas, Arizona, Florida, Georgia, Idaho, Indiana, Kansas, Maine, Michigan, Missouri, Mississippi, North Carolina, New Mexico, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Wisconsin, West Virginia.