Remote Clinical Review Nurse - Denials & UM Improvement

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

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.