Clinical Appeals Review Nurse

Remote Clinical Appeals Review Nurse

Job Description:

Managed Resources Inc works with many of the largest and most prestigious healthcare organizations in the nation to locate and evaluate top talent for their organizations. Currently we have a client that is in need of experienced Clinical Appeals Review Nurses . Please read the below description and apply if you meet the requirements and would like to hear more about the opportunity.

Clinical Appeals Review Nurse Clinical Appeals Review at MRI services consists of reviewing and appealing for reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not Medically Necessary.

Job Duties: The Clinical Appeals Review Nurse will review the case, and determine the potential for a Provider Appeal, on the denied claim.

The request for reconsideration will be written in an objective narrative form, utilizing appropriate formatting, English grammar, current nationally accepted criteria, medical literature if applicable, healthcare statutes and clinical judgment.

Once completed, the letter will be forwarded to the Clinical Appeals Manager for review and approval and then to the payer source for reconsideration.

The Clinical Appeals Review nurse will provide the application of current prudent clinical judgment for the purpose of the case in question.

The diagnosis, treatment of an illness, injury, and/or disease of its symptoms, will be in accordance with generally accepted standards of medical practice.

The clinical review of the denied stay will be evaluated in terms of type, frequency, extent, site and duration of patient’s illness and/or injury or disease.

The clinical review of the case will not be based on convenience factors for the patient, facility, physician, and/or other health care professionals.

The Clinical Appeal Review Nurse will receive appropriate documentation which includes previous determination information and complete medical record for review.

The review will be written in a narrative, professional manner, with an appropriate review of the clinical facts. The letter will include the medically appropriate reasons for the reconsideration of the denial.

License, Registration or Certification Required: Registered Nurse (RN)

Job Type: Full-time

Required license or certification:

• Registered Nurse (RN)