Appeals Nurse

Job not on LinkedIn

🔥 1 minute ago

⛰️ Colorado, Florida, +13 more states – Remote

⛰️ Colorado – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌾 Nebraska – Remote 🏖️ New Jersey – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🌴 South Carolina – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – Remote

💵 $66k - $68k / year

⏰ Full Time

🟢 Junior

👻 Ghost score 0%

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📋 Description

• Review and assess first-level appeal cases for denied services • Ensure relevant medical documentation, coding, and clinical information support each appeal • Conduct comprehensive medical record reviews to determine clinical necessity of services • Make recommendations for resolution based on clinical guidelines, policy, and medical necessity of care • Prepare and submit written appeal letters with comprehensive rationales and supporting clinical evidence • Follow up on appeals and ensure proper resolution in accordance with company policies and external regulations • Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process • Work with and provide direction to Redetermination Representatives • Ensure clinically determined redeterminations are responded to within CMS quality and timeline standards • Collaborate with Appeals Examiners/Reps to complete medical reviews and redeterminations timely

🎯 Requirements

• Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN) • Active RN license, applicable to state of practice in good standing • One (1) or more years of clinical experience in a healthcare setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.) • Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely • Strong attention to detail and organizational skills to manage multiple cases simultaneously • Basic knowledge and understanding of medical/clinical review processes (i.e., Appeals/Utilization Review) • Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel • Experience working for a Medicare Administrative Contractor (MAC) preferred • One (1) or more years of experience working in Medical Management, Medical Review, Utilization Management/Review, or Appeals preferred • Basic Medicare knowledge and/or experience preferred • Wired (ethernet cable) internet connection from router to computer • High speed cable or fiber internet connection • Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection • Subject to applicable federal regulations, CMS contract requirements, and WPS internal policies, including data security, privacy, confidentiality, and program integrity requirements • Subject to screening and background investigation including fingerprinting prior to access to information systems and/or sensitive data

🏖️ Benefits

• Remote and hybrid work options available • Performance bonus and/or merit increase opportunities • 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately) • Competitive paid time off • Health insurance, dental insurance, and telehealth services start DAY 1 • Professional and Leadership Development Programs

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