Job Title: Clinical Review RN (Independent Dispute Resolution/Appeals)

Experience: Open to various clinical backgrounds/experience. Appeals experience not required. Must have 2+ years of clinical experience post clinicals. Must has strong computer skills, critical thinking and problem solving skills.

***Must have BSN and New York State RN license***

Location: Remote (can sit anywhere in the US as long as you can work EST hours)Remote (can sit anywhere in the US as long as you can work EST hours)??????? 

Hours of Operation: M-F between operating hours of 7a-5:30p *flexible start between 7am-9am (40hrs/wk)

Start date: ASAP

Pay: $50-53/hr DOE

Volume: Will do appeals work under the IDR team handling on average 10 cases a day. These will be a mix between simple and complex cases. They will be reviewing documentation, codes, and more for out of Network bills and cost and making determinations on how to move forward based on the evidence.

This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical level review, Prior Authorization, and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

DUTIES:

1. Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements, complete electronic worksheets and preparing final determinations.
2. Act as a resource for the administrative and clinical staff in training, problem solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles.
3. Training and mentoring new RNs as the project expands.
4. Claims assessment and adjudication.
5. Participate in collaborative training.
6. Other activities as may be deemed necessary.

QUALIFICATIONS:

1. Knowledge and experience with electronic medical records.
2. Ability to oversee, problem solve, and work collaboratively with peers, medical, analytical, and administrative support staff.
3. Excellent written and verbal skills.
4. Ability to work independently with little supervision.
5. Ability and desire to be flexible, innovative, and creative.

EDUCATION AND EXPERIENCE:

1. Licensed, Registered Nurse, required in New York
2. Baccalaureate degree in Nursing
3. Minimum of two years’ experience in a clinical setting, required.

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.