State Licensed Clinical RN Specialist

Job Summary

Evaluating hospitalizations remotely, the full-time State Licensed Clinical RN Specialist will perform retrospective medical necessity reviews and draft appeals to establish the medical necessity of diagnoses in question, utilizing strong clinical knowledge and coding certifications.

Key responsibilities:

• Perform retrospective medical necessity reviews to determine appeal eligibility for clinical validation DRG Downgrade denials
• Construct and document fact-based clinical cases to support appeals using appropriate medical necessity criteria
• Adhere to coding and clinical documentation guidelines as endorsed by ACDIS and AHIMA

Required qualifications:

• Active unrestricted clinical license as an RN or MD in at least one state within the United States
• Certification in coding through AAPC (CPC/COC) or AHIMA (CCS/CCS-P)
• Minimum of 5 years recent acute-care hospital experience
• At least 2 years of Utilization Review / Case Management experience within the last 5 years
• Strong written communication skills and computer proficiency