Appeals Registered Nurse

Role Snapshot The Appeals Nurse examines medical records and claims information for first-level appeal cases to determine whether services provided were medically necessary and meet Medicare coverage guidelines in accordance with Medicare regulations and policies. The Appeals RN works in collaboration with the Appeals Examiners/Reps to ensure redeterminations are medically reviewed as needed and completed timely. Salary Range 66-68k The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Location We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin How do I know this opportunity is right for me? If you are interested in the following activities: Review and assess first-level appeal cases for denied services, ensuring all relevant medical documentation, coding, and clinical information are provided to support the appeal. Conduct comprehensive medical record reviews to determine the clinical necessity of services and make recommendations for resolution based on clinical guidelines, policy, and the medical necessity of care. Prepare and submit written appeal letters, including comprehensive rationales and supporting clinical evidence. Ensure timely follow-up on all appeals and ensure proper resolution is reached in accordance with company policies and external regulations. Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process, ensuring all actions comply with regulatory and contractual requirements. Work with and provide directions to Redetermination Representatives to ensure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards. Minimum Qualifications Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).