Remote Nurse - Full Time or PRN

Account Control Technology Holdings, Inc.
Gainesville, VA Remote Full Time
POSTED ON 9/28/2022 CLOSED ON 3/1/2023

Job Posting for Remote Nurse - Full Time or PRN at Account Control Technology Holdings, Inc.

Duties

  • Serve as a clinical resource, provide clinical expertise, and clinical guidance to the team, as well as our client hospitals.
  • Work with the company’s Attorneys and Account Specialists to overturn claims denied by Commercial insurers, Medicare, Medicaid, and other third-party payers.
  • Conduct medical chart reviews by reviewing all clinical documentation. Clinically validate the medical appropriateness, and coding accuracy, of services rendered in both inpatient and outpatient settings.
  • Reviews admissions for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides case management and/or consultation for complex cases.
  • Assists departmental staff with issues related to medical records/documentation, precertification, reimbursement, and claim denials/appeals
  • Create narrative rationale in response to audit and chart review determinations
  • Craft and submit medical necessity and clinical appeals that get denials overturned, as well as guide attorneys to write winning appeals
  • Review clinical policies and guidelines, i.e. NCD/LCD coverage documents, carrier-specific policies related to investigational or experimental procedures, and readmissions.
  • Perform chart audits to validate charges as they relate to the services rendered, based on medical documentation
  • Maintain current knowledge of Medicare and Commercial Insurance trends, regulations, and policies.
  • Perform other related duties as required


Requirements


  • Licensed RN –license must be active and in good standing.
  • Minimum two to five years as a Clinical Appeals Nurse with a main focus on recovering payment for hospitals. Previous work with an Insurance company will be considered as well.
  • Experience in defending government audits such as RAC.
  • Experience/Knowledge in all clinical areas, both inpatient and outpatient, including but not limited to, Cardiology, Pediatrics, Medical-Surgical, Trauma and E.R., Cancer, and Behavioral Health.
  • Excellent verbal and written communication skills; ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as the ability to understand and interpret complex information from others.
  • Team Player - works well as a member of a group

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