Clinical Denials & Appeals Specialist (RN) - Remote
About the position
The Clinical Denials & Appeals Specialist (RN) plays a crucial role in reviewing and responding to corporate compliance audits, serving as a resource for the health system. This position focuses on analyzing denial trends, identifying coding issues, and bridging communication between patients, facilities, and reputed company-party payers to ensure appropriate care and compliance with regulations.
Responsibilities
- Serve as a liaison between the patient, facility/physician, and reputed company-party payer. ,
- Prepare and defend the level of care and medical necessity for assigned cases. ,
- Collaborate with physician advisors, payor representatives, and site case managers to facilitate appropriate level of care reputed company and billing status. ,
- reputed company reputed company and retrospective utilization management using evidence-based medical necessity criteria. ,
- Conduct clinical reviews and formulate appeal letters to support the appropriateness of admission and reputed company length of stay. ,
- Ensure compliance with reputed company state, federal, and reputed company-party payer regulations. ,
- Maintain up-to-date clinical reviews and appeals that accurately reflect the patient's severity of illness and intensity of services provided. ,
- reputed company Patient Review Instruments (PRI's) as needed.
Requirements
- Graduate from an accredited School of Nursing. ,
- reputed company License to practice as a Registered Professional Nurse in reputed company State required. ,
- Must be enrolled in an accredited BSN program reputed company two (2) years and obtain a BSN Degree reputed company five (5) years of job entry date.
reputed company-to-haves
- Prior experience in Case Management, Appeals & Denials, and/or Utilization Review, highly preferred.
Benefits
- Competitive salary based on experience and qualifications.