Clinical Appeals Nurse

Elevate Patient Financial Solutions®; United States; A distancia; USD 70.000 - 90.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, Dental & Vision Insurance

401K (100% match for the first 3% & 50

15 days PTO

7 paid Holidays

2 Floating holidays

1 Elevate Day (floating holiday)

Pet Insurance

Employee referral bonus program

Teamwork: We believe in teamwork and a

Career Growth: Gain great experience

Descripción de la vacante

Elevate Patient Financial Solutions is seeking a Clinical Appeals Nurse to serve as the liaison for denials and appeals received after claim submission. This role is remote and full-time, working Monday through Friday 8:00am–4:30pm CST.

You will manage clinical denials and appeals with payers, review appeal letters for accuracy, and communicate outcomes with stakeholders. A valid RN license is required, with CCM preferred and at least two years in utilization review, case management, or

Formación

• Two years Utilization Review/Case Management in managed care or hospital setting.
• Experience with denial and appeal processes is preferred.
• Familiar with medical terminology and regulatory standards.

Responsabilidades

• Serve as liaison for clinical denials and appeals after claim submission.
• Evaluate appeal letters for content, clarity, and accuracy.
• Package and send appeal information to payors and track outcomes.
• Communicate denial/appeal activity to stakeholders and report trends.
• Participate in audit findings review.

Conocimientos

Regulatory compliance knowledge

Medicare knowledge

Professional communication

Critical thinking

Educación

RN license

Herramientas

Microsoft Word

Microsoft Excel

Descripción del empleo

Elevate Patient Financial Solutions has an exciting career opportunity available as an Clinical Appeals Nurse. This position will be Remote Work from Home. The Full Time schedule for this role will be Monday - Friday 8:00am -4:30pm CST.

Job Summary

The Clinical Appeals Nurse is the liaison and point of contact for clinical denials and appeals that are received after claim submission. Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care.

Essential Duties And Responsibilities

• Use their clinical knowledge, experience, and advanced critical thinking to ensure accuracy and integrity of the full life cycle of medical necessity denial determinations is properly administered.
• Evaluate clinical appeal letter correspondence for content, clarity, accuracy, and consistency.
• Package & send appeal and grievance information to the payors, monitors for the outcome of appeal and takes action accordingly (notify the provider and member as per delegation agreement), track all appeal information.
• Actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
• Participate in the review of audit findings as needed.
• Regular and timely attendance.
• Other duties as assigned.

Qualifications And Requirements

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or abilities.
• Apply professional standards of practice in the work environment to both internal and external customers
• Knowledge of regulatory standards, compliance requirements, hospital policies and procedures, and third party requirements
• Familiar with medical terminology
• Strong understanding and working knowledge of Medicare and Commercial admission regulations
• Familiar with third-party admission and continued stay criteria
• Working knowledge of personal computer and software applications used in job functions (Word processing, graphics, databases, spreadsheets, etc.)
• A minimum of two years of Utilization Review/Case Management experience in either a managed care or hospital setting is required
• A minimum of two years’ experience in the denial and appeal process preferred
• RN license, in good standing and maintained current throughout employment
• CCM, preferred
• Remote and Hybrid positions require home internet connections that meet the company’s upload and download speed criteria.

Benefits

ElevatePFS believes in making a positive impact not only within our industry but also with our employees –the organization’s greatest asset! We take pride in offering comprehensive benefits in a vast array of plans that contribute to the present and future well‑being of our employees and their families.

• Medical, Dental & Vision Insurance
• 401K (100% match for the first 3% & 50% match for the next 2%)
• 15 days of PTO
• 7 paid Holidays
• 2 Floating holidays
• 1 Elevate Day (floating holiday)
• Pet Insurance
• Employee referral bonus program
• Teamwork: We believe in teamwork and having fun together
• Career Growth: Gain great experience to promote to higher roles

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, location, specialty and training. This pay scale is not a promise of a particular wage.

The job description does not constitute an employment agreement between the employer and Employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

ElevatePFS is an Equal Opportunity Employer