Clinical Review Specialist - RN - Appeals Writing

 About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. 

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

JOB SUMMARY:

ESSENTIAL DUTIES AND RESPONSIBILITIES: 
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

Location: Remote within the United States ONLY

Schedule: Monday - Friday, 8:00 AM - 5:00 PM

As a Clinical Review Specialist (RN), you will have the unique opportunity to evaluate hospitalizations across the country while utilizing your medical knowledge and gaining experience as an expert advisor. You will perform retrospective clinical case reviews and draft appeals that focus on establishing the Medical Necessity of the services performed, both Inpatient and Outpatient.

Essential Duties and Responsibilities:

·       Performs retrospective medical necessity reviews to determine appeal eligibility of clinical disputes/denials.

·       Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts.

o   Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.

·       Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appeal process.

Minimum Qualifications & Competencies:

·       RN License with strong clinical knowledge - Active unrestricted clinical license in at least one state within the United States.

·       Minimum of 2-3 years of writing appeals letters and clinical auditing.

·       Minimum of 2-3 years Utilization Review / Case Management experience within the last 5 years.

·       Must be familiar with the payer guidelines and EMR systems like Epic, Cerner or Meditech.

·       Managed care payor experience a plus in either Utilization Review, Case Management or Appeals.

·       Must have excellent attention to detail, written communication skills and be computer proficient.

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.