Clinical Appeals Nurse

Netsmart; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Netsmart is seeking a qualified nurse to review medical records and prepare clinical appeals in response to denials and DRG reassignments for hospital clients. The role requires strong clinical judgment and experience in medical record review.

Responsibilities include presenting oral arguments during Administrative Law Judge hearings and using Medicare guidelines, local coverage determinations, and best practices to support appeals.

Qualifications

• RN with a BSN and active state licensure is required.
• Minimum 5 years of clinical experience in an acute care setting.
• At least 3 years in case management or utilization management.

Responsibilities

• Review medical records and prepare clinical appeals for denials and DRG reassignments.
• Utilize Medicare guidelines, local/national determinations, and best practices to support appeals.
• Participate in telephonic Administrative Law Judge hearings and present oral arguments.

Skills

Clinical appeals analysis

Medical record review

Strong written communication

Education

Bachelor of Science degree in Nursing

RN licensure (state)

Tools

MS Word

Job description

Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and DRG reassignments.

Responsibilities

• Prepare professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients.
• Utilize industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, and best practice standards, as well as a broad knowledge base and sound clinical judgment in reviewing medical records and writing appeals.
• Participate in telephonic Administrative Law Judge Hearings and present oral arguments for reversing Medicare denials.

Qualifications

Required

• Bachelor of Science degree in Nursing
• Current state RN licensure
• At least 5 years of clinical experience in acute care setting
• At least 3 years of case management, concurrent review or utilization management experience
• Proficiency in medical record review
• Superior written communication skills
• Proficiency with MS Word

Preferred

• Payer case management experience

Expectations

• Able to flex hours during the day depending on the training schedule including some evenings and weekends
• Normal office environment including but not limited to: long periods of sitting, typing, analyzing data, telephone communication, use of standard office equipment and daily personal interaction.

Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart's sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart's third party screening provider.

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All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.

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