Appeals Registered Nurse

5 - 7 years experience  •  Healthcare IT

Salary depends on experience
Posted on 10/23/17
Saint Louis, MO
5 - 7 years experience
Healthcare IT
Salary depends on experience
Posted on 10/23/17

Job Description:


  • Perform medical record reviews of requested services within specified department timelines.
  • Apply advanced clinical knowledge for the interpretation and evaluation of clinical data in order to determine compliance with established criteria
  • Prepare case documents for cases requiring physician review to ensure a comprehensive clinical picture is presented facilitating accurate and timely decision making by the physician
  • Process appeals from investigation to resolution according to CMS regulations and department policies and procedures within the timeliness standards
  • Prepare and present select appeals to the multi-disciplinary AppealsCommittee.  
  • Complete post-service requests for claim redetermination reviews as requested.
  • Document completely and accurately within an electronic clinical record
  • Provide education on the appeals process to members and providers as requested
  • Maintain HIPAA standards and ensure confidentiality of protected health information
  • Ensure compliance with all state and federal regulations and guidelines in day-to-day activities
  • Perform special projects as assigned


  • Licensed Registered Nurse (RN) in the state of Missouri is required, eligible for licensure in other states as required
  • Minimum 5years clinical nursing experiencerequired
  • 2+ years experienceutilization review, denial management, audits and appeals, clinical documentation improvement or related expertise
  • Proficient knowledge of Medicare/Managed Care guidelines preferred
  • Working knowledge of medical necessity criteria

Knowledge, skills, and ability required:

  • Strong verbal and written communication skills
  • Strong problem solving skills
  • Strong attention to details
  • Strong customer service skills
  • Excellent organization skills for prioritizing tasks to meet set deadlines
  • Ability to multi-task and self-motivate
  • Proficient knowledge of Medicare and HIPAA regulations
  • Professional demeanor and the ability to work effectively within a team or independently
  • Strong computer skills including Microsoft Office 
  • 1+ years of experience in Appeals, preferred
  • 1+ years of experience in Managed Care preferred


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