Clinical Appeals RN — Denials & Medical Necessity Expert

Hornet Staffing, Inc, a GEE Group company; Columbia (SC); On-site; USD 65,000 - 85,000; Full time

Job summary

Hornet Staffing, Inc., a GEE Group company, seeks an RN reviewer to join our clinical review team in the United States. The role focuses on reviewing medical records, determining medical necessity, and evaluating provider appeals/denials with attention to coding accuracy and policy adherence.

The incumbent will rely on 3 years of clinical experience (or 2 years plus 1 year in utilization/medical review, quality assurance, or home health) and hold an active RN license.

Qualifications

• 3 years of clinical experience, or 2 years of clinical experience plus 1 year in utilization/medical review, quality assurance, or home health.
• Active RN license in the state of hire or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
• Healthcare insurance experience preferred.

Responsibilities

• Researches and reviews medical records and provider appeals/denials to determine medical necessity and appropriate coverage.
• Documents decisions and ensures they meet mandated timeframes and regulatory standards.

Skills

Active RN license

Education

Associate Degree in Nursing or graduate of an accredited School of Nursing

Job description

Hornet Staffing, Inc., a GEE Group company, seeks an RN reviewer to join our clinical review team in the United States. The role focuses on reviewing medical records, determining medical necessity, and evaluating provider appeals/denials with attention to coding accuracy and policy adherence.

The incumbent will rely on 3 years of clinical experience (or 2 years plus 1 year in utilization/medical review, quality assurance, or home health) and hold an active RN license.