DRG Nurse Reviewer Appeals and Hearings- Remote

Sign-on bonuses are available for highly qualified candidates.

Summary

We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.

Your role in our mission

• Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
• Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
• Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
• Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
• Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
• Responsible for attending training and scheduled meetings to enhance skills and working  knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.

What we're looking for

• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required
• 5+ years clinical experience or 5+ years medical record coding experience preferred
• Working knowledge of the appeals and hearings process
• Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
• Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions.
• Ability to multi-task in a fast-paced production environment.

What you should expect in this role

• Remote (Work from Home)
• Up to 25% Travel for onsite hearing testimony

This position is for pipeline purposes, and we welcome applications on an ongoing basis.