DRG Nurse Reviewer Appeals and Hearings- Remote

Responsibilities

• Coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers
• Review documentation to ensure all aspects of the appeal have been addressed properly and accurately
• Prepare case files and case summaries for hearings
• Participate in in virtual and on-site hearings
• Afford assistance to management with training new reviewers to include daily monitoring, mentoring, feedback and education
• Maintain current knowledge of clinical criteria guidelines and/or coding guidelines; successfully complete required CEUs to maintain RN license and/or coding certification
• Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations
• Actively cross-train to perform reviews of multiple claim types to provide a flexible workforce to meet client needs

Requirements

• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA)
• 5+ years clinical experience or 5+ years medical record coding experience

Qualifications

Your role in our mission
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 to include 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 to meet client needs.

Skills

• Working knowledge of the appeals and hearings process
• Excellent written communication skills including 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

Benefits

In this role, you will be eligible for remote work up to 25%, occasional travel for onsite hearing testimony, a competitive salary range of $95,000.00 - $110,000.00 per year, a generous vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also offer a variety of leadership and technical development academies to help build your skills and capabilities.

Pay & Schedule

The pay range for this position is $95,000.00 - $110,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Schedule

Remote (Work from Home)

Application Instructions

We welcome applications on an ongoing basis. To apply, please visit our Careers site for all available job role openings.