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

📋 Description

• Assess medical record documentation to confirm medical necessity concerns related to length of stay, level of care, readmissions, experimental/investigational procedures, and more.

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

• Oversee inventory management and follow up on accounts as necessary.

• Examine InterQual/Milliman and/or payer medical policies concerning denied procedures or services, incorporating relevant criteria into the analysis/appeal letter as needed.

• Provide insights to the supervisor regarding identified issues to support ongoing training for peers and non-clinical staff members.

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

⛳️ Requirements

• Current RN license required.

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

• 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 reviewing CMS LCD/NCD criteria is preferred.

• Strong typing and computer skills are crucial.