Clinical Appeals Nurse - Remote / Telecommute

Cynet Systems; Raleigh (NC); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider is seeking a Clinical Appeals Nurse for a remote role. This position involves investigating and analyzing appeals, preparing cases for physician review, and ensuring compliance with regulations. Ideal candidates will have a nursing background and strong analytical skills. Join a dynamic team dedicated to quality patient care and regulatory compliance.

Qualifications

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

Responsibilities

• Investigates and analyzes written appeals from various sources.
• Organizes appeal cases for physician review and communicates final decisions.
• Interacts with Regulatory Agencies regarding complaints.

Skills

Communication

Critical Thinking

Analytical Skills

Problem Solving

Education

High School Diploma

BSN/MSN Degree

Tools

Microsoft Office

Job description

Clinical Appeals Nurse - Remote / Telecommute

Join to apply for the Clinical Appeals Nurse - Remote / Telecommute role at Cynet Systems

Clinical Appeals Nurse - Remote / Telecommute

1 day ago Be among the first 25 applicants

Join to apply for the Clinical Appeals Nurse - Remote / Telecommute role at Cynet Systems

Get AI-powered advice on this job and more exclusive features.

• 35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stakeholders 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 accreditation 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.

Job Description:

Essential Functions:

• 35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stakeholders 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 accreditation 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.

Preferred Needed 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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Education Level: High School Diploma
• Experience- 2 years medical-surgical or similar clinical experience OR 3 years experience in mental health, psychiatric setting.
• BSN/MSN Degree
• 2 years experience in Medical Review, Utilization Management or Case Management at Client Client Client, or similar Managed Care organization or hospital preferred.

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.

Licenses/Certifications:

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

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Contract

Job function

• Job function

  Health Care Provider

Referrals increase your chances of interviewing at Cynet Systems by 2x

Sign in to set job alerts for “Registered Nurse” roles.

Admission RN, Full-time (Sign-on Bonus Available)

Registered Nurse - $70,000 Minimum Pay - Sign-on Bonus Offered - Longleaf NMT Center

Registered Nurse - $70,000 Minimum Pay - Sign-on Bonus Offered - Central Regional Hospital

Registered Nurse (2nd shift) - ***$12,000 Sign-on Bonus Offered*** - Whitaker PRTF

Chapel Hill, NC $60,820.00-$98,680.00 2 months ago

Night Shift RN / LPN Pediatric Home Health Nurse

Raleigh, NC $58,898.00-$88,348.00 4 months ago

Nurse Supervisor I - $10,000 Sign-on Bonus Offered - Whitaker PRTF

Registered Nurse (RN) ICU, Cary Hospital

Apex, NC $67,000.00-$87,000.00 6 months ago

Murdoch - Registered Nurse - 2nd Shift - $70,000 Min Pay- Sign On Bonus $10,000

Murdoch - Registered Nurse - 3rd Shift- $70,000 Min Pay - Sign on Bonus $10,000

Licensed Practical Nurse - Sign-on Bonus Offered - Longleaf NMT Center

Chapel Hill, NC $60,820.00-$98,680.00 4 months ago

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.