Clinical Denials & Appeals Specialist (RN) - Remote
About the position Responsibilities • Serve as a liaison between the patient, facility/physician, and third-party payer. • Prepare and defend the level of care and medical necessity for assigned cases. • Collaborate with physician advisors, payor representatives, and site case managers to facilitate appropriate level of care decisions and billing status. • Perform concurrent and retrospective utilization management using evidence-based medical necessity criteria. • Conduct clinical reviews and formulate appeal letters to support the appropriateness of admission and continued length of stay. • Ensure compliance with current state, federal, and third-party payer regulations. • Maintain up-to-date clinical reviews and appeals that accurately reflect the patient's severity of illness and intensity of services provided. • Perform Patient Review Instruments (PRI's) as needed. Requirements • Graduate from an accredited School of Nursing. • Current License to practice as a Registered Professional Nurse in New York State required. • Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date. Nice-to-haves • Prior experience in Case Management, Appeals & Denials, and/or Utilization Review, highly preferred. Benefits • Competitive salary based on experience and qualifications. Apply tot his job