Clinical Nurse Specialist

Accede Solutions Inc (accedesolution.com); Michigan; Remote; USD 55,000 - 83,000; Full time

Job summary

Accede Solutions Inc. is hiring a Remote Clinical Review Nurse (Concurrent Review) for a 12-month contract. The role focuses on NCQA-aligned clinical reviews and drafting correspondence letters related to denial determinations for Medicaid products in IL and MI.

You will collaborate with the correspondence team to maintain letter templates, investigate denials through clinical documentation, and coordinate with state, local, and federal agencies to resolve issues in a timely manner.

Qualifications

• Must be a graduate from an accredited school of nursing.
• RN with an Associate or Bachelor's degree required.

Responsibilities

• Drafts and edits denial letters based on review outcomes per NCQA standards.
• Investigates denials via clinical documentation, criteria, and policy.
• Coordinates with agencies and third parties to resolve issues.
• Maintains logs and documents actions for timely resolution.
• Supports training needs within the utilization management team.
• Provides feedback to leadership to improve processes and prevent recurrences.

Skills

Clinical review

NCQA standards

Denial letter drafting

Utilization management

Agency communications

Education

RN degree (ADN/BSN)

Job description

**REMOTE** Clinical Review Nurse - Concurrent Review

12 months contract

This candidate will be working with the IL and MI Medicaid product, Meridian.

Position Purpose:

Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.

• Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards
• Contributes to correspondence letter template creation and maintenance with the correspondence team
• Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims
• Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
• Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
• Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
• Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Requirements:

• Requires graduated from an accredited school of nursing or Associate or bachelor's in nursing.