Clinical Appeals Nurse (Healthcare)

Location: Remote within the United States; applicants must be legally authorized to work in the United States

Company

hirify.global provides healthcare technology and services for healthcare organizations.

What you will do

• Review medical records and prepare clinical appeals for medical necessity denials and DRG reassignments.
• Prepare appeals responding to managed care, governmental, and RAC denials for hospital clients.
• Apply industry guidelines, Medicare Benefit Policy Manual guidance, national and local coverage determinations, and best-practice standards.
• Participate in telephonic Administrative Law Judge hearings and present oral arguments to support reversal of Medicare denials.

Requirements

• Bachelor of Science degree in Nursing.
• Current state RN licensure.
• At least 5 years of clinical experience in an acute care setting.
• At least 3 years of case management, concurrent review, or utilization management experience.
• Proficiency in medical record review, superior written communication skills, and proficiency with Microsoft Word.
• Legal authorization to work in the United States is required; visa sponsorship is not available.

Nice to have

• Payer case management experience.

Culture & Benefits

• Full-time remote work with a normal office environment.
• Schedule flexibility may be required during training, including some evenings and weekends.
• Work involves extended periods of sitting, typing, data analysis, telephone communication, and use of standard office equipment.
• Equal opportunity and affirmative action workplace committed to inclusion.
• Post-offer background check and drug screening are required for employment.