Clinical Appeals Nurse

Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and DRG reassignments.Responsibilities

Prepare professional, effective clinical appeals in response to 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, as well as a broad knowledge base and sound clinical judgment in reviewing medical records and writing appeals.

Participate in telephonic Administrative Law Judge Hearings and present oral arguments for reversing Medicare denials.

Qualifications
Required

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

Preferred
Payer case management experience

Expectations

Able to flex hours during the day depending on the training schedule including some evenings and weekends

Normal office environment including but not limited to: long periods of sitting, typing, analyzing data, telephone communication, use of standard office equipment and daily personal interaction.

Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.
Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.
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Originally posted on Himalayas