Clinical Registered Nurse - Utilization Management - Remote

Cognizant; Dover (DE); Remote; USD 70,000 - 74,000; Full time

Job summary

A healthcare solutions provider is seeking a Remote Registered Nurse to manage clinical denial processes. Key responsibilities include reviewing medical necessity denials and submitting determinations to health plans. Candidates should have RN credentials and relevant experience in utilization management and clinical operations. This position offers an annual salary between $70,000 and $74,000 along with comprehensive benefits.

Benefits

Medical/Dental/Vision/Life Insurance

Paid holidays plus Paid Time Off

401(k) plan and contributions

Long-term/Short-term Disability

Paid Parental Leave

Employee Stock Purchase Plan

Qualifications

• 2-3 years combined clinical and/or utilization management experience with a managed healthcare plan.
• 3 years’ experience in healthcare revenue cycle or clinic operations.
• Experience in clinical appeals and grievances, precertification, and reviews.

Responsibilities

• Manage clinical denial processes and documentation.
• Draft medical necessity determinations for health plans.
• Identify denial patterns to mitigate risks.

Skills

Clinical denial management

Utilization management

Critical thinking

Microsoft Office

In-patient and outpatient experience

Education

Registered Nurse (RN)

Tools

Epic

Job description

Overview

Schedule: Monday to Friday - Eastern Time

Location: Remote

About the role

As a Registered Nurse you will make an impact by performing advanced level work related to clinical denial management and managing clinical denials from Providers to the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member of the Cognizant team and work collaboratively with stakeholders and other teams.

Responsibilities

• Maintain ownership and responsibility for assigned accounts.
• Maintain working knowledge of applicable health insurers’ internal claims, appeals, and retro-authorization as well as timely filing deadlines and processes.
• Review clinical denials including but not limited to referral, preauthorization, medical necessity, non-covered services, investigational/experimental and billing resulting in denials and/or delays in payment.
• Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and third-party guidelines.
• Effectively document and log claims/appeals information on relevant tracking systems
• Utilize critical thinking skills to interpret guidelines of internal policies for clinical determination.
• Medical Necessity Reviews can be based on InterQual, Milliman Clinical Guidelines (MCG), Medicare guidelines, and health insurer specific guidelines.
• Review retro-authorizations in accordance with health insurer requirements and follow insurer process guidelines.
• Identify denial patterns with clients to mitigate risk and minimize regulatory penalties.
• Escalate potential risks to client, client partners and/or leadership.
• Demonstrates critical thinking skills to interpret guidelines of internal policies for clinical determination

Additional information

We strive to provide flexibility wherever possible. Based on this role’s business requirements, this is a remote position open to qualified applicants in United States. Regardless of your working arrangement, we are here to support a healthy work-life balance though our various wellbeing programs.

The working arrangements for this role are accurate as of the date of posting. This may change based on the project you’re engaged in, as well as business and client requirements. Rest assured; we will always be clear about role expectations.

What you need to have to be considered

• Educational background - Registered Nurse (RN)
• 2-3 years combined clinical and/or utilization management experience with managed health care plan
• 3 years’ experience in health care revenue cycle or clinic operations
• Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews
• Intermediate Microsoft Office knowledge (Excel, Word, Outlook)
• In-patient and outpatient experience

These will help you stand out

• Epic experience
• Experience in drafting appeals disputing inpatient clinical validations audits is a plus.

Salary, Benefits & Other Information

Salary: The annual salary for this position is between $70,000 - $74,000 depending on the experience and other qualifications of the successful candidate.

This position is also eligible for Cognizant’s discretionary annual incentive program and stock awards, based on performance and subject to the terms of Cognizant’s applicable plans.

Benefits : Cognizant offers the following benefits for this position, subject to applicable eligibility requirements:

• Medical/Dental/Vision/Life Insurance
• Paid holidays plus Paid Time Off
• 401(k) plan and contributions
• Long-term/Short-term Disability
• Paid Parental Leave
• Employee Stock Purchase Plan

Disclaimer : The salary, other compensation, and benefits information is accurate as of the date of this posting.

Cognizant reserves the right to modify this information at any time, subject to applicable law.

Cognizant will only consider applicants for this position who are legally authorized to work in the United States without requiring company sponsorship now or at any time in the future.

Cog2025

Cognizant is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.