Clinical Appeals Nurse

Netsmart • North Little Rock, AR

2d • Onsite

About The Position

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

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
• Must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.

Nice To Haves

• Payer case management experience

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.

Benefits

• Equal employment and advancement opportunities to all individuals.
• Celebrates diversity and is committed to creating an inclusive environment for all associates.
• All employment decisions are based on performance, qualifications, abilities, education and experience.
• 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.
• Provides a healthy and safe workplace.
• Maintains a drug-free workplace in accordance with applicable federal law.
• Pre-employment background check, including a drug screen, provided at Netsmart’s sole expense.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior