Clinical Appeals Nurse - Remote / Telecommute

Cynet Systems; Owings Mills (MD); Remote; Full time

Job summary

Cynet Systems is seeking a skilled Registered Nurse for a case review position in Owings Mills, MD. The ideal candidate will possess clinical experience with strong analytical skills to assess appeals and provide informed recommendations. The role requires effective communication with stakeholders and a commitment to regulatory standards. Opportunities for advancement and professional growth in a fast-paced environment are available.

Qualifications

• 2 years of medical-surgical or similar clinical experience OR 3 years experience in mental health.
• RN - Registered Nurse licensure required.
• Excellent verbal and written communication skills.

Responsibilities

• Investigates and analyzes written appeals and requests.
• Prepares cases for physician review and communicates decisions.
• Maintains knowledge of medical practices and procedures.

Skills

Communication

Critical thinking

Analytical skills

Problem solving

Customer service

Education

High School Diploma

BSN/MSN Degree

Tools

Microsoft Office

Job description

Job Description:

Pay Range: $39.71hr - $44.71hr

Essential Functions:

• 35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators.
• Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates.
• 35% Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence.
• Formulates recommendations for disposition.
• Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights.
• 25% Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate.
• Interpret and apply, as appropriate Regulatory and accredidation requirements.
• Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate.
• Interacts and responds to complaints from Regulatory Agencies and CMS.
• 5% Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.

Qualifications:

• 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 ability required.
• accommodations may be made to enable individuals with disabilities to perform the essential functions.
• High School Diploma.

Experience:

• 2 years medical-surgical or similar clinical experience OR 3 years experience in mental health, psychiatric setting.

Preferred Qualifications:

• 2 years experience in Medical Review, Utilization Management or Case Management at Client Client, or similar Managed Care organization or hospital preferred.
• BSN/MSN Degree.

Knowledge, Skills and Abilities:

• Knowledge and understanding of medical terminology., Advanced
• Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals., Proficient
• Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task. , Proficient
• Ability to effectively communicate and provide positive customer service to every internal and external customer., Advanced
• Knowledge of Microsoft Office programs., Proficient
• Excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions., Proficient
• The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
• Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Licenses/Certifications:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required.
• CCM - Certified Case Manager Upon Hire Preferred.
• LNCC - Legal Nurse Consultant Certified Upon Hire Preferred.