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RN-Clinical Appeals (Remote)

Job ID: RNCLI01368
Updated: October 16, 2018
Geographic Location: 
Full/Part Time: 
Standard Hours: 
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(This position can work Remotely)

The Registered Nurse - Clinical Appeals is a responsible for drafting, finalizing and sending clinical appeal letters in order to reverse a denial for payment on insurance claim. The RN will begin by reviewing account specifics and evaluating how to follow up with the payer on the denied claim. The RN will use the provided tools and patient medical records, working within and through the regulations to develop a documented response to the denial and overturn the payer's decision. RN will be responsible for appealing inpatient medical necessity/level of care denials using various applicable criteria such as Milliman (MCG), InterQual, etc. RN will also be responsible for appealing other various denials using clinical based rationale. Clinical appeals are to be professional, appropriate with respect to the denial reason, grammatically correct, supported by medical records as applicable and of the standard to be maintained as supporting documents for the claim. The RN will stay current with assigned accounts and follow-up on the appeal after submission. Following the action taken within the letter, the RN notes all accounts appropriately per the objective quality standard.


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