Licensed RN Appeals Nurse

Job Summary

Working remotely, the Licensed RN Appeals Nurse will review medical records, create clinical analyses and appeal letters, and manage accounts to overturn clinical denials from Medicare, Medicaid, and other third-party payers.

Key responsibilities

• Review medical record documentation to verify medical necessity issues related to claims
• Create detailed clinical analyses and appeal letters to support payment of patient claims
• Identify root causes and trends to share with clients and staff for ongoing training and improvement

Required qualifications

• Licensed RN with at least 2 years of experience in an acute care hospital
• 3 to 5 years of experience in utilization review, case management, or related fields preferred
• Experience using InterQual and Milliman healthcare criteria preferred
• Familiarity with CMS LCD/NCD criteria preferred
• Proficient typing and computer skills essential