What are the responsibilities and job description for the Remote Appeals RN position at The Judge Group Inc.?
Location: REMOTE
Salary: $28.00 USD Hourly - $30.00 USD Hourly
Description: Our client is currently seeking a Remote Appeals RN!
This job will have the following
responsibilities:
Please email your resume with the required qualifications to Nabyla Feitosa at NMendesFeitosa@judge.com for immediate consideration!
Contact: nmendesfeitosa@judge.com
This job and many more are available through The Judge Group.
Find us on the web at www.judge.com
Salary: $28.00 USD Hourly - $30.00 USD Hourly
Description: Our client is currently seeking a Remote Appeals RN!
- RNs MUST have a TN or COMPACT License!
- Candidates can reside anywhere in EST or CST time zones only!
(NO MST OR PST! ) - Ongoing contract 6 months w/ possible extensions
- Mon-Fri, business hours
This job will have the following
responsibilities:
- Performs comprehensive pre-existing reviews, reviews of rider-related diagnoses, potential misrepresentation referrals, rider related drug appeals, provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, nursing judgement, and contractual eligibility .
- Performs thorough research and provides complete documentation for rationale to support determinations as well as specific written instructions regarding additional information necessary to complete the review.
- Performs or participates in special studies or projects/pilots as directed by departmental management.
- Cross functional and accomplished in all ancillary review functions.
- May mentor/trains new incumbents and serve as a preceptor.
- Seek the advice of the Medical Director when medical judgment is required.
- Initiate referrals to accomplish discharge planning when such plans are evident at the time of the request e.g., telephone request for scheduled for total hip replacement.
- Assist non-clinical staff in performance of administrative reviews.
- Interact with Onsite and Case Management areas to ensure smooth transfer of member information across the continuum of care.
- Apply established vendor protocols for authorization processes
- Serves as a presentation guide for walk-through surveyors, auditors, group representatives, etc.
- Active TN or Compact State RN license
- Must reside in EST or CST time zones
- Minimum 3 years varied clinical experience
- Experience will be denials/appeals for Medicare
- Proficient knowledge and ability to apply various accreditation requirements (URAC, NCQA, etc.)
. - Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria preferred.
- Ability to maintain professional and courteous internal communication with various departments, particularly Claims, in the exchange of information.
- Must be PC literate with extensive knowledge of Windows and Microsoft Office.
Must be able to pass Windows navigation test. - Must possess excellent verbal and written communication skills with problem-solving abilities as well as organizational and interpersonal skills.
- Must be able to work independently and handle multiple tasks.
- Customer service oriented
- Must be adaptive to high pace and changing environment
Please email your resume with the required qualifications to Nabyla Feitosa at NMendesFeitosa@judge.com for immediate consideration!
Contact: nmendesfeitosa@judge.com
This job and many more are available through The Judge Group.
Find us on the web at www.judge.com
Location/Region: Atlanta, Georgia
Salary : $28 - $30
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