Clinical Appeals Nurse

🔥 2 hours ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 DRG reassignments • Prepare professional, effective clinical appeals for managed care, governmental, or RAC denials for hospital clients • Utilize industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, and best practice standards when reviewing medical records and writing appeals • Participate in telephonic Administrative Law Judge Hearings • Present oral arguments for reversing Medicare denials

🎯 Requirements

• Bachelor of Science degree in Nursing • Current state RN licensure • At least 5 years of clinical experience in acute care setting • At least 3 years of case management, concurrent review or utilization management experience • Proficiency in medical record review • Superior written communication skills • Proficiency with MS Word • Able to flex hours during the day depending on the training schedule, including some evenings and weekends • All applicants 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 • Preferred: Payer case management experience

🏖️ Benefits

• Equal employment and advancement opportunities • Pre-employment background check and drug screen provided at Netsmart’s sole expense • Healthy and safe workplace • Full-time employment