Nurse Reviewer Appeals and Hearings- Remote

Gainwell Technologies LLC•Any city, OH

8d•$80,000 - $99,200•Remote

About The Position

We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings role to coordinate and perform all appeal-related duties, including analyzing and responding appropriately to provider appeals; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; preparing case files and case summaries for hearings; and participating in virtual and on-site hearings. Your role in our mission includes reviewing provider appeals and redeterminations using approved clinical and coding guidelines, and documenting appeal determinations clearly and concisely. You will analyze and review appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. You will also prepare case files and case summaries for hearings and actively participate in hearings in conjunction with the Medical Director. Additionally, you will assist management with training new reviewers, including daily monitoring, mentoring, feedback, and education. Maintaining current knowledge of clinical criteria guidelines and/or coding guidelines and successfully completing required CEUs to maintain RN license and/or coding certification is crucial. You will be responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-training to perform reviews of multiple claim types is expected to provide a flexible workforce that meets client needs.

Requirements

Active, unrestricted RN license in the United States and primary home residency; active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
5+ years of clinical experience or 5+ years of medical record coding experience required.
3+ years of utilization review experience or claims auditing required.
Working knowledge of the appeals and hearings process.
Excellent written communication skills, including the ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
Excellent oral communication skills, with particular emphasis on verbally presenting case summaries and decisions.
Ability to multi-task in a fast-paced production environment.

Nice To Haves

Experience using MCG or InterQual criteria preferred.

Responsibilities

Reviews provider appeals and redeterminations using approved clinical and coding guidelines, and documents appeal determinations clearly and concisely.
Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
Assists management with training new reviewers, including daily monitoring, mentoring, feedback, and education.
Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce that meets client needs.