About this role
Role Overview
- Uses nationally recognized evidence-based utilization review criteria to assess and write up clinical reviews for insurance audits and governmental insurance appeals using supporting documentation
- Assesses the appropriateness of clinical appeal requests by using payer policies and Federal and State regulations
- Works with Physician Advisors to obtain clinical support for appeals if needed
- Collaborates with Care Management, Utilization Review, Physician Advisors, Revenue Integrity, Compliance, Legal Counsel and the RCO teams to prepare appeals
- Identifies trends and works with the appropriate multidisciplinary teams to improve denial management, documentation and appeals processes
- Supports and works with legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process
Requirements
- Graduate of an accredited school of nursing is required
- Three (3) years experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting required
- Current valid RN License is required
- Bachelor’s degree (BSN) is preferred
Benefits
- Generous benefits package
- Flexible work options