Clinical Appeals Service (RN) | Work from Home with Annual Increase!

Connext Global Solutions is a dedicated team of business process outsourcing experts and innovators, with experience in supporting world-class companies in Title and Escrow, Healthcare, Produce Distribution, Retail and Fashion, Design Consulting, and Finance.

We are currently looking for a Registered Nurse who will be working as a Clinical Appeals Service with Connext's Client in the United States of America.

What's in it for you?

• Competitive compensation

• Perfect Attendance Bonus

• Life insurance

• HMO Insurance

• Great company culture

• Annual Merit Increase

• 25% Night Differential

• Work from Home!

What is the job?

The Clinical Appeals Service is responsible for performing audits of medical records on behalf of hospital clients to support denial reviews, defense audits, disallowed charge evaluations, and utilization reviews.

Responsibilities:

• Conduct comprehensive audits of medical records to support or dispute charges, including defense and payer-requested audits.

• Evaluate medical necessity and care appropriateness using standardized criteria and payer-specific guidelines (e.g., Medicare, Medicaid, commercial plans).

• Prepare and submit detailed appeal letters addressing both clinical and contractual issues for various audit types (e.g., RAC, ZPIC, CERT).

• Collaborate with physicians, hospitals, and patients to gather necessary supporting documentation and medical literature.

• Manage multiple audit cases simultaneously, ensuring accurate data entry and timely resolution using electronic systems (e.g., EMRs, billing platforms).

• Maintain compliance with HIPAA, FDCPA, FCRA, and payer requirements while safeguarding patient confidentiality and staying current with audit regulations.

Qualifications:

• Registered Nurse (RN)

• At least three (3) to five (5) years of clinical experience or equivalent in auditing, Medicare appeals, utilization review, or denials management.

• Experienced in medical records review, claims processing, and clinical case management.

• In-depth knowledge of Medicare and Medicaid regulations and compliance standards.

• Skilled in navigating electronic medical records and multiple healthcare systems efficiently.

• Strong analytical, critical thinking, and clinical interpretation abilities.

• Highly detail-oriented with a focus on accuracy in documentation and case evaluation.

• Proficient in Microsoft Office; professional, customer-focused, and committed to ongoing learning and excellence.