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Clinical Appeals Review Nurse Jobs in Fremont, Iowa

Medical Review Nurse (Government Outpatient Clinical Focus)
By Performant Financial Corporation At , Remote
Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Knowledge of insurance programs program, particularly the coverage and payment rules.
Medical Review Nurse (Snf Focus)
By Performant Financial Corporation At , Remote
Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Knowledge of insurance programs program, particularly the coverage and payment rules.
Medical Review Nurse (Readmissions Focus)
By Performant Financial Corporation At , Remote
Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Knowledge of insurance programs program, particularly the coverage and payment rules.
Excellent written and verbal communication skills.
Ability to manage multiple tasks including desk audits and claims review.
Minimum of three years diversified nursing experience providing direct care in an inpatient or outpatient setting.
Appeals And Grievances Quality Nurse
By WellSense Health Plan At , Remote
Maintains current knowledge of regulatory, contractual and accreditation requirements subject matter expert
2+ years of experience in a managed care healthcare setting
2+ years of Utilization Management (Helpful)
Comprehensive knowledge of Medicaid and Medicare contractual provisions and NCQA accreditation requirements highly desirable
Exceptional customer service skills and experience working with diverse populations required
Assists with calibration sessions in accordance with department standards, to help ensure consistency and validation of audit parameters, KPIs, and requirements
Medicare Advantage Appeals And Grievance Nurse
By Blue Cross and Blue Shield of Kansas City At , Remote
Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals.
Competitive benefits package with day one eligibility
Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
Formulates determination language that resolves member or provider issues in a manner consistent with regulatory and accrediting agency requirements
Provides training, leadership and mentoring for less experienced appeal RN and administrative staff.
2 years of appeals and UM experience in a payer-based environment
Appeals Nurse Consultant Jobs
By CVS Health At , Hartford $58,760 - $125,840 a year

Must have active and unrestricted RN licensure in state of residence

California RN license preferred (not required)

Clinical Quality Review Nurse Trainer/Auditor - Consultant
By Blue Shield of California At , Woodland Hills, 91367 $109,120 - $163,680 a year
Conduct periodic needs assessments to identify knowledge gaps
Requires a bachelors degree or equivalent experience
Requires at least 7 years of prior relevant experience
Requires 3-5 plus years hands-on clinical experience across a variety of specialties and settings
Preferred Nursing Informatics experience and/or degree
Strong verbal/written communication and organizational skills
Rn Appeals Nurse (Hybrid)
By VillageCare At New York, NY, United States

Appeals Nurse (Hybrid) VillageCareMAX 112 Charles Street, New York, NY 10014 VillageCare is looking for a self-motivated and passionate RN for our Appeals Nurse position. While supporting the ...

Nurse Appeals (Contract) Jobs
By Elevance Health At , Los Angeles
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
Medical Review Nurse (Government Outpatient Clinical Focus)
By Performant Corp At United States
Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Knowledge of insurance programs program, particularly the coverage and payment rules.
Clinical Review Nurse I
By Elevance Health At Hingham, MA, United States
Medicare Part B Appeals experience preferred.
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider grievances and appeals.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Adapts to a wide variety of medical review topics in Part B appeals.
Clinical Review Nurse I
By Elevance Health At Atlanta, GA, United States
Medicare Part B Appeals experience preferred.
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider grievances and appeals.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Adapts to a wide variety of medical review topics in Part B appeals.
Nurse Appeals Jobs
By Elevance Health At Florida, United States
Job Family: Medical and Clinical
National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint
Resolving member clinical grievances (complaints).
Conducts investigations and reviews of member grievances and potential quality of care issues.
Reviews medical records for potential quality of care issues.
Extrapolates and summarizes medical information for medical director.
Nurse Appeals Jobs
By Elevance Health At United States
Job Family: Medical and Clinical
National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint
Resolving member clinical grievances (complaints).
Conducts investigations and reviews of member grievances and potential quality of care issues.
Reviews medical records for potential quality of care issues.
Extrapolates and summarizes medical information for medical director.
Clinical Appeals Nurse Jobs
By Netsmart At United States
At least 3 years of case management, concurrent review or utilization management experience
Prepare professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients.
At least 5 years of clinical experience in acute care setting
Participate in telephonic Administrative Law Judge Hearings and present oral arguments for reversing Medicare denials.
Bachelor of Science degree in Nursing
Proficiency in medical record review
Clinical Review Nurse Jobs
By Abbott At Kansas City, MO, United States
3-5 years’ minimum experience in Occupational health settings, hospital, and outpatient nursing
Career development with an international company where you can grow the career you dream of.
Free medical coverage for employees* via the Health Investment Plan (HIP) PPO
An excellent retirement savings plan with high employer contribution
Provide subject matter expertise in executing Drug Testing Services across Workplace Solutions broad customer base.
Interpret and report results of Workplace clients consistent with Workplace Solutions written Standard Operating Procedures.
Appeals Nurse Jobs
By Netsmart At United States
At least 3 years of case management, concurrent review or utilization management experience
Prepare professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients.
At least 5 years of clinical experience in acute care setting
Participate in telephonic Administrative Law Judge Hearings and present oral arguments for reversing Medicare denials.
Bachelor of Science degree in Nursing
Proficiency in medical record review
Appeals Nurse Jobs
By Mindlance At Ohio, United States
Experience with Utilization Review/Management--2 yrs
Utilization review nurse, appeal review nurse and direct patient care experience.
Share resume at : [email protected]
Behavior and accountability and ability to pivot when new priorities come up
Describe the performance expectations/metrics for this individual and their team:
What previous job titles or background work will in this role?
Nurse Appeals Jobs
By Elevance Health At Ashburn, VA, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Nurse Appeals Jobs
By Elevance Health At Columbus, OH, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.

Are you a Clinical Appeals Review Nurse looking for a new challenge? Join our team and help us make a difference in the lives of our patients! We offer a competitive salary and benefits package, as well as a supportive and collaborative work environment. Come join us and make a difference today!

Overview A Clinical Appeals Review Nurse is responsible for reviewing and evaluating appeals from healthcare providers and patients regarding denied claims. They must be knowledgeable in medical coding and billing, as well as the appeals process. They must be able to identify and resolve discrepancies in claims and provide accurate and timely decisions. Detailed Job Description A Clinical Appeals Review Nurse is responsible for reviewing and evaluating appeals from healthcare providers and patients regarding denied claims. They must be knowledgeable in medical coding and billing, as well as the appeals process. They must be able to identify and resolve discrepancies in claims and provide accurate and timely decisions. They must be able to interpret and apply medical policies and procedures, as well as state and federal regulations. They must be able to communicate effectively with healthcare providers and patients, as well as other departments within the organization. Job Skills Required
• Knowledge of medical coding and billing
• Knowledge of the appeals process
• Ability to interpret and apply medical policies and procedures
• Ability to identify and resolve discrepancies in claims
• Ability to provide accurate and timely decisions
• Excellent communication and interpersonal skills
• Ability to work independently and as part of a team
• Proficiency in computer applications
Job Qualifications
• Bachelor’s degree in Nursing or related field
• Current RN license
• 3+ years of experience in medical coding and billing
• Knowledge of medical terminology
• Knowledge of state and federal regulations
• Knowledge of the appeals process
Job Knowledge
• Knowledge of medical coding and billing
• Knowledge of the appeals process
• Ability to interpret and apply medical policies and procedures
• Ability to identify and resolve discrepancies in claims
• Knowledge of medical terminology
• Knowledge of state and federal regulations
Job Experience
• 3+ years of experience in medical coding and billing
• Experience in the appeals process
• Experience in interpreting and applying medical policies and procedures
• Experience in identifying and resolving discrepancies in claims
Job Responsibilities
• Review and evaluate appeals from healthcare providers and patients regarding denied claims
• Interpret and apply medical policies and procedures, as well as state and federal regulations
• Identify and resolve discrepancies in claims
• Provide accurate and timely decisions
• Communicate effectively with healthcare providers and patients, as well as other departments within the organization