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Nurse Specialist II, Clinical Denials
Knowtion Health. Review medical record documentation to verify medical necessity issues related to length of stay, level of care, readmissions, experimental/investigational services, and similar matters .
About the role
Key responsibilities & impact- Review medical record documentation to verify medical necessity issues related to length of stay, level of care, readmissions, experimental/investigational services, and similar matters
- Create detailed clinical analyses and appeal letters for payer denials to support payment of patient claims
- Manage inventory and follow up on accounts as appropriate
- Review InterQual/Milliman and/or payer medical policies related to denied procedures or services and include criteria in analyses and appeal letters as appropriate
- Provide feedback to the supervisor regarding issues identified for ongoing training of peers and non-clinical staff
- Identify root causes and trends to share with clients and staff
- Work with attorneys and claims representatives to review and appeal claims when appropriate to overturn clinical denials from Medicare, Medicaid, and other third-party payers
Requirements
What you’ll need- Licensed RN required
- At least 2 years of experience in an acute care hospital required
- Three to five years of experience in utilization review, case management, quality assurance, discharge planning, or other cost management programs preferred
- Experience using InterQual and Milliman healthcare criteria preferred
- Experience reviewing CMS LCD/NCD criteria preferred
- Proficient typing and computer skills essential
- Valid government-issued photo ID required during screening and/or interviews
- Applicants located in the following states are prioritized: Alabama, Arkansas, Arizona, Florida, Georgia, Idaho, Indiana, Kansas, Maine, Michigan, Missouri, Mississippi, North Carolina, New Mexico, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Wisconsin, West Virginia
Benefits
Comp & perks- Medical insurance
- Dental insurance
- Vision insurance
- Life insurance
- Short-term disability
- Long-term disability
- Bonus opportunities
- Paid holidays
- 401(k)
- Generous PTO policy
- Dedicated, distraction-free work space at home