Job Title: Appeals RN

Target Candidate Background: Must be an LPN/LVN or RN with 1-2 years of Appeals experience + clinical acute care experience required. 

Training hours: 9am-4pm EST

Work hours: Must be able to work 9am-3pm but can choose your start and end time before 9am or after 3pm to work a full 40 hours, Monday-Friday.

Location: Remote (can sit anywhere but ideally in CST or EST timezones

Pay: $41-45/hr

Position Purpose:
Performs complex (senior-level) work. Provides dissatisfied patients/beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. Provides an independent second level determination/dispute resolution based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

Essential Responsibilities:

• Reviews medical records/case file, writes a reconsideration/dispute resolution decision that is clear, concise, and impartial and supports the determination made, and documents review.
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy.
• Responds to and ensures that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
• Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures.
• Participates in case specific verbal discussions.
• Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
• Plans responses to statistical analysis challenges with assistance from statisticians.
• Attends meetings and participates in workgroups at the direction of management.
• Conducts quality reviews, as needed.
• Serves as a subject matter expert.
• Mentors and/or trains staff.
• May conduct quality reviews and audits.
• Participates in special projects and performs other duties as assigned.

Minimum Qualifications

• Associate's degree or Bachelor’s degree in nursing
• Must have nursing license for the state you reside in 
• 1-2 years of medical dispute resolution or Medicare appeals, medical review, and clinical experience
• Demonstrated experience writing or making medical necessity decisions  
• Demonstrated experience writing or making appeal or payment determinations

Knowledge, Skills and Abilities
• Strong computer skills  
• Research techniques
• Medical terminology
• Medicare program, including coverage and payment rules
• Medicare regulations, claims administration, and medical review processes
Expert skill in:
• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
• Researching, analyzing and interpreting policies and state and federal laws and regulations

^*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.