Job Summary: Talent Software Services is in search of a Registered Nurse for a contract-to-hire position that can be worked 100% remotely.
Primary Responsibilities/Accountabilities:
Our Appeals Nurse will examine medical records and claims information for first-level appeal cases to determine whether services provided were medically necessary and meet Medicare coverage guidelines in accordance with Medicare regulations and policies. In addition, this role will:
Utilize clinical knowledge and clinical review judgment to conduct medical review of claim documentation for first-level appeal cases.
Provide clear and concise written explanations for reason a specific claim or set of claims cannot be paid as a result of first-level redetermination.
Work with and provide direction to Redetermination Representatives to assure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards.
Analyze appeals and identify specific high-volume problem issues and relay information to Redeterminations Manager and Senior Analyst.
Participate in various workgroups for purposes of Continuous Quality Improvement (CQI) to promote consistent medical review of claim documentation and information.
Collaborating with a team of clinicians and non-clinicians.
Learning a variety of systems, including but not limited to, the Medicare Appeal System (MAS) which is a content management system for Part A appeals and our Hyland OnBase tool which is our content management system used for Part B appeals.
Experience working in an environment that serves our nation's military, veterans, Guard and Reserves, and Medicare beneficiaries.
Working in a continuous performance feedback environment.
Qualifications:
Associate's (ASN) or Bachelor's Degree in Nursing (BSN)
Active RN license, applicable to state of practice in good standing
Have moved away from direct patient care and want to continue using your nursing knowledge in a new and different way.
Excel at analyzing information and critical thinking to make sound medical decisions.
Are highly organized and adept at researching and finding answers independently using all available resources.
Thrive in a production environment where quality and production metrics are critical to individual and team success.
Have strength in technical writing.
Desire day hours with no on-call work and holidays off.
Are technically strong on computers including MS Outlook, Teams, OneNote, Word, and Excel.
Are self-motivated and work with a great degree of independence.
Are looking for a full-time, permanent position.
Preferred:
Experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals
Strong technical writing skills
Strong computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.
4 or more years of experience in clinical nursing
Experience outside of direct patient care.
Experience working with Medicare Part A and Part B
Previous experience working for another Medicare Administrative Contractor (MAC)
Experience working in a remote work environment!
If this job is a match for your background, we would be honored to receive your application!
Providing consulting opportunities to TALENTed people since 1987, we offer a host of opportunities including contract, contract to hire and permanent placement. Let's talk!
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other
Industries
IT Services and IT Consulting
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