Clinical Appeals RN - Remote - M-F working alternating Saturdays
About The Position
The Clinical Appeals RN provides expertise in clinical appeals and grievances by analyzing, reviewing, and evaluating cases. The role also acts as a Clinical Interface Liaison, helping resolve clinical issues with facilities, providers, and carriers related to members, benefits, program definitions, and clarification. The position is remote within the U.S. The schedule is generally Monday through Friday, 8:00 a.m. to 4:30 p.m. in the employee’s time zone, with alternating Saturdays (two per month) and a weekday off when working a Saturday. The posting also notes hours of Monday through Friday, 8:00 a.m. to 5:00 p.m., and requires comfort with mandatory overtime.
Requirements
- Active, unrestricted RN license in the state of residence.
- At least 2 years of RN clinical experience, including experience in an acute inpatient hospital setting.
- Proficiency in Microsoft Office, Word, Outlook, and internet applications.
- Availability to work Monday through Friday, 8:00 a.m. to 4:30 p.m. in the employee’s time zone, and alternating Saturdays (two per month, with a weekday off when working a Saturday).
- Comfort working mandatory overtime.
Nice To Haves
- Bachelor of Science in Nursing.
- At least 1 year of experience using MCG and/or Medicare criteria.
- At least 1 year of experience in Utilization Management, pre-authorization, concurrent review, or appeals.
- Appeals experience.
- Excellent communication, interpersonal, problem-solving, and analytical skills.
Responsibilities
- Review medical records and verify whether requested services meet criteria.
- Review pre-service appeals for clinical eligibility for coverage under Plan benefits.
- Review and interpret Plan language.
- Coordinate reviews with the Medical Director.
- Use clinical guidelines and criteria.
- Accurately document determinations.
- Adhere to confidentiality regulations and agreements.
- Serve as a Clinical Interface Liaison to help resolve issues with facilities, providers, and carriers concerning members, benefits, and program definitions or clarification.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase plan.
- 401(k) contribution, subject to eligibility requirements.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
