Clinical Appeals Nurse - Remote / Telecommute

Cynet Systems Inc; Raleigh (NC); Remote; USD 60,000 - 75,000; Full time

Job summary

A leading healthcare organization is seeking a skilled RN to manage and analyze appeals and reconsideration requests. The ideal candidate will possess strong clinical expertise and communication skills, ensuring compliance with regulatory standards while delivering high-quality patient care. This role involves collaborating with physicians and regulatory agencies to uphold corporate policies and make informed decisions on coverage appropriateness. Join a dynamic team committed to improving patient outcomes in a supportive environment.

Qualifications

• 2 years of medical-surgical or similar clinical experience OR 3 years in mental health settings.
• Experience in Medical Review, Utilization Management, or Case Management preferred.

Responsibilities

• Investigates and analyzes written appeals and reconsideration requests.
• Organizes appeal cases for physician review and communicates final decisions.
• Maintains knowledge of medical practices and terminology.

Skills

Communication

Critical Thinking

Analytical Abilities

Education

High School Diploma

BSN/MSN

Tools

Microsoft Office

Job description

Job Description

Essential Functions:

1. 35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stakeholders, and others.
2. Responds to such requests with original, complex, and technical letters, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates.
3. 35% Organizes the appeal case for physician review by compiling clinical, contractual, medical policy, and claims information along with corporate and appellant correspondence.
4. Formulates recommendations for disposition.
5. Prepares the written case for review and communicates the final decision to the member and providers after physician review, including an explanation of the decision and external appeal rights.
6. 25% Investigates, interprets, analyzes, and prioritizes appeal requests using nursing expertise and clinical information for medical and behavioral health conditions, medical policies, to assess the appropriateness of adverse coverage and decisions.
7. Interprets and applies regulatory and accreditation requirements as appropriate.
8. Collaborates with Independent Review Organizations and contracted Panel Physicians to obtain clinical opinions from specialists to evaluate adverse decisions.
9. Responds to complaints from Regulatory Agencies and CMS.
10. 5% Maintains current knowledge of medical practices, procedures, and terminology across various health disciplines, including mental health and substance abuse treatments.

Preferred Needed Qualifications:

• High School Diploma required; BSN/MSN preferred.
• 2 years of medical-surgical or similar clinical experience OR 3 years in mental health or psychiatric settings.
• Experience in Medical Review, Utilization Management, or Case Management within Managed Care or hospital settings is preferred.

Knowledge, Skills, and Abilities:

• Strong understanding of medical terminology, regulatory and accreditation standards, and appeals processes.
• Excellent verbal and written communication skills, with strong listening, critical thinking, and analytical abilities.
• Proficiency in Microsoft Office programs.
• Ability to assess medical necessity and appropriateness of care, including mental health and substance use issues.

Licenses/Certifications:

• RN - Registered Nurse license (State or Compact required).
• CCM - Certified Case Manager (preferred).
• LNCC - Legal Nurse Consultant Certified (preferred).