Clinical Appeals RN
CareNational
Date: 5 days ago
City: Toledo, OH
Contract type: Contractor
Remote Registered Nurse (RN) - Clinical Appeals
Position Type: Remote, Contract (3-4 months)
Pay Range: $40.00 / Hour
Schedule: M-F 8-5pm EST
Job Overview
Education and Experience:
Position Type: Remote, Contract (3-4 months)
Pay Range: $40.00 / Hour
Schedule: M-F 8-5pm EST
Job Overview
- Independently evaluates basic to complex medical claims and/or appeal cases and associated records by applying clinical, regulatory, and policy and procedures knowledge and experience to assess the appropriateness of service provided, length of stay and level of care
- Extrapolates and summarizes medical information for physician review or other external review
- Generates appropriate written status of review to providers, members, and regulatory entities advising of status
- Acts as a resource to the provider community, explaining processes for accessing health plan to perform clinical review, identifying appropriate community resources, or otherwise interacting with health plan programs and services
- Orients, trains, and provides guidance to more junior or less experienced staff. Facilitates work assignments
- Collaborates with providers, members, and various internal departments to ensure that members are getting appropriate care at the most appropriate time
- Keeps up to date on utilization management regulations, policies, and practices, including applicable coding
- Performs other duties as assigned
Education and Experience:
- RN OH license/Compact RN license required. Bachelor’s degree preferred
- MCO/Health Plan experience required.
- 3 years’ experience as a Registered Nurse in acute care, critical care, emergency medical or medical surgical or a combination of clinical and utilization/case management experience in the health insurance industry
- Experience in clinical documentation improvement, medical coding or medical documentation investigation preferred
- Registered Nurse with current State of Ohio unrestricted license OR Compact RN License
- Strong clinical knowledge and understanding of health care delivery processes
- Familiarity with medical terminology and managed care processes
- Familiarity with clinical claim management including ICD 10, CPT, HCPC, and revenue codes
- Familiarity with health care regulations
- PC and keyboarding proficiency; Intermediate Microsoft Office skills
- Ability to mentor and share knowledge
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