Clinical Appeals Nurse (PRN)
Netsmart•North Little Rock, AR
•Remote
About The Position
Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and diagnosis-related groups (DRG) reassignments.
Requirements
- Bachelor's of Science in Nursing (BSN) or equivalent degree
- Current and unrestricted RN license
- At least 5 years of clinical experience in acute care settings
- At least 3 years of experience in case management, utilization review, or clinical appeals
- Exceptional written and verbal communication skills
- Proficiency with MS Office suite, particularly Word and Excel
- Strong analytical and problem-solving skills with attention to detail
Nice To Haves
- Experience with payer-side case management or medical director-level review
Responsibilities
- Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients
- Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments
- Participate in Administrative Law Judge (ALJ) Hearings, presenting oral arguments to support the reversal of Medicare denials
- Analyze denial patterns and contribute insights to help reduce future denials
- Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes
- Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process
Benefits
- drug-free workplace
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What This Job Offers
Job Type
Part-time
Career Level
Senior
