Clinical Appeals Nurse, PRN

🔥 12 hours ago

🇺🇸 United States – Remote

⏱ Part Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 10%

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Netsmart

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1973

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

Netsmart is a leading provider of comprehensive EHR solutions tailored for a wide range of care settings, especially in behavioral health, addiction treatment, autism, geriatrics, and intellectual and developmental disabilities. The company offers a range of software products that streamline operations, enhance care coordination, and promote value-based care across healthcare communities. In addition to EHRs, Netsmart provides technology solutions for care coordination, telehealth, population health management, and revenue cycle management, aiming to support the delivery of integrated and person-centered care. Their solutions are used in a variety of sectors including human services, post-acute care, and public health, making Netsmart a significant player in the healthcare technology industry.

📋 Description

• Review medical records and prepare clinical appeals in response to medical necessity denials and diagnosis-related group (DRG) reassignments • Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients • Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments • Participate in Administrative Law Judge (ALJ) Hearings and present oral arguments to support reversal of Medicare denials • Analyze denial patterns and contribute insights to help reduce future denials • Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes • Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process

🎯 Requirements

• Bachelor's of Science in Nursing (BSN) or equivalent degree • Current and unrestricted RN license • At least 5 years of clinical experience in acute care settings • At least 3 years of experience in case management, utilization review, or clinical appeals • Exceptional written and verbal communication skills • Proficiency with MS Office suite, particularly Word and Excel • Strong analytical and problem-solving skills with attention to detail • Preferred: Experience with payer-side case management or medical director-level review • Comfortable with remote work arrangements and virtual collaboration tools • Must be legally authorized to work in the United States • Netsmart does not provide work visa sponsorship for this position • Successful completion of a pre-employment background check, including a drug screen

🏖️ Benefits

• Part-time employment • Occasional travel for conferences, client meetings, or in-person hearings • Pre-employment background check and drug screen provided at Netsmart’s sole expense