Responsibilities

• Prepare professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients.

• Utilize industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, and best practice standards, as well as a broad knowledge base and sound clinical judgment in reviewing medical records and writing appeals.

• Participate in telephonic Administrative Law Judge Hearings and present oral arguments for reversing Medicare denials.

Qualifications
Required

• Bachelor of Science degree in Nursing

• Current state RN licensure

• At least 5 years of clinical experience in acute care setting

• At least 3 years of case management, concurrent review or utilization management experience

• Proficiency in medical record review

• Superior written communication skills

• Proficiency with MS Word

Preferred

• Payer case management experience

Expectations

• Able to flex hours during the day depending on the training schedule including some evenings and weekends

• Normal office environment including but not limited to: long periods of sitting, typing, analyzing data, telephone communication, use of standard office equipment and daily personal interaction.