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Clinical Appeals Nurse
3 months ago
Job Title: Clinical Appeals Nurse Contract: 3-month assignment Scheduled Weekly hours: 40 Hours. Location: Remote (anywhere within the U.S.) - *Ohio License Is Required The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states. Essential Functions: *Responsible for the completion of clinical appeals and state hearings from all states *Review and complete all provider clinical appeals within required timeframes. *Review and complete member clinical appeals within required timeframes. *Review all information necessary to prepare State Hearing packets. *Communicate with state agencies and internal departments to prepare for State Hearings *Attend assigned State Hearing and completed all required compliances. *Complete required compliances for Administrative Hearing decisions *Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals. *Issue notification letters to providers and members. *Issue administrative denials appropriately. *Refer denials based on medical necessity to medical director. *Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates. *Conduct monthly, quarterly, and ad hoc appeals reporting. *Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Review *Ensure compliance with regulatory and accrediting requirements. *Perform any other job duties as requested. Education and Experience: *RN License required. *Associate degree or equivalent years of relevant experience required. *Managed care, appeals, and Medicaid experience preferred. *Utilization review experience is strongly preferred. * Competencies, Knowledge, and Skills: *Intermediate proficiency with Microsoft Office products and Facets *Knowledge of NCQA, URAC, OAC, and MDCH regulations *Strong written and oral communication skills *Ability to work independently and within a team environment. *Critical listening and thinking skills. *Proper grammar usage *Time management skills *Proper phone etiquette *Customer Service oriented *Decision making/problem solving skills. *Familiarity of healthcare field *Knowledge of Medicaid *Flexibility *Change resiliency. Licensure and Certification: *Current, unrestricted license as a Registered Nurse (RN) is required. *MCG Certification is required or must be obtained within six (6) months of hire. PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law. It is the policy of the Company to provide equal employment opportunities to all qualified individuals and to administer all aspects and conditions of employment without regard to the following: • Race and associated traits, including hairstyle; Color, Age, Sex, Sexual orientation, Gender, Gender identity and gender expression; Religion, including dress and grooming practices; National origin, including language use restrictions; Pregnancy, childbirth, or breastfeeding; Marital or familial status; Genetic information, including family medical history; Physical or mental disability; Citizenship and/or immigration status • Medical conditions, including cancer, AIDS/HIV, and occupational pneumoconiosis without respiratory impairment • Denial of family or medical care leave • Use of a guide or support animal • Military
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Clinical Appeals Specialist
17 hours ago
Dayton, Ohio, United States Professional Management Enterprises Full timeJob Title: Clinical Appeals Specialist**Job Summary:**We are seeking a highly skilled Clinical Appeals Specialist to join our team at Professional Management Enterprises. As a Clinical Appeals Specialist, you will be responsible for the completion of clinical appeals and state hearings from all states.Key Responsibilities:Review and complete all provider...
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Registered Nurse
1 week ago
Dayton, Nevada, United States Clinical Management Consultants Full timeClinical Management Consultants is seeking a skilled Registered Nurse specializing in Surgical Services to join a reputable healthcare facility. This organization is committed to delivering exceptional patient care and is located in a picturesque area that offers a blend of natural beauty and modern amenities.This comprehensive health system encompasses a...
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Clinical Resource Advisor
1 week ago
Dayton, Ohio, United States Premier Health Partners Full timePosition: Physician AdvisorDepartment: Physician AdvisorsShift: Full Time 8am - 5pm / 40 hours per week with an option to maintain clinical competencies.Premier Health Partners, a distinguished nonprofit academic health organization in Southwest Ohio, is committed to delivering exceptional medical services across various acute care hospitals, outpatient...
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Clinic Nurse
1 month ago
Dayton, United States Family Allergy & Asthma Full timeJob DescriptionJob DescriptionDescription:Job Title: Clinic Nurse Work Schedule: Full-TimeEmployment Classification: Non-exempt, Hourly Travel Required: Yes- Centerville home location 3 days per week and Beavercreek 1 day per week. Position SummaryThe Clinic Nurse is responsible for demonstrating knowledge and application of job duties within scope of...
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Clinical Resource Advisor
1 week ago
Dayton, Ohio, United States Premier Health Partners Full timePosition: Physician AdvisorDepartment: Physician AdvisorsShift: Full Time 8am - 5pm / 40 hours per week with an option to maintain clinical skillsPremier Health Partners, a nonprofit academic health organization in Southwest Ohio, is committed to delivering exceptional medical services across various acute care hospitals, outpatient facilities, physician...
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Clinical Resource Advisor
3 days ago
Dayton, Ohio, United States Premier Health Partners Full timePosition: Physician AdvisorDepartment: Physician AdvisorsShift: Full Time 8am - 5pm / 40 hours per week with option to maintain support clinical skillsPremier Health Partners, a private nonprofit academic health system in Southwest Ohio, is dedicated to providing exceptional medical services across various acute care hospitals, outpatient facilities,...
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Clinical Nurse Specialist
1 week ago
Dayton, Ohio, United States NaphCare Full timePosition Overview:NaphCare is seeking dedicatedClinical Nurse Specialiststo become part of our esteemed team.We offer various employment options including Full-Time, Part-Time, PRN, and temporary contracts ranging from 8 to 13 weeks. The specific shifts and hours will be determined by the needs of the facility and the availability of PRN staff.NaphCare is a...
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Travel Nurse RN
4 days ago
Dayton, Ohio, United States Travel Nurse Source Full timeTravel Nursing Opportunity in a Dynamic Healthcare EnvironmentTravelNurseSource is partnering with TotalMed Staffing to find a qualified Stepdown RN for a travel assignment in a fast-paced, dynamic healthcare setting.About the PositionWe are seeking a skilled Step Down Unit Registered Nurse to provide high-quality patient care and contribute to a...
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Clinical Nurse Specialist
1 week ago
Dayton, Ohio, United States The Laurels of West Carrollton LLC Full time$7,500 SIGN ON BONUS for any FULL TIME RNs CURRENT AVAILABLE POSITIONS: FULL TIME 6A-6P AND 6P-6A FULL TIME WEEKEND WARRIOR 6A-6P PRN ALL SHIFTS Are you a proactive thinker, an effective communicator, and dedicated to providing care for the elderly? As a Clinical Nurse Specialist at The Laurels of West Carrollton, you will have the chance to utilize your...
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Clinical Faculty Position
20 hours ago
Dayton, Ohio, United States Hondros College of Nursing Full timeJob SummaryHondros College of Nursing is seeking a dynamic and experienced nurse to join our team as a Full-Time Clinical Faculty member. As a key member of our faculty, you will play a vital role in shaping the next generation of nursing professionals.ResponsibilitiesTeaching and Mentoring: Instruct students in the lab and/or clinical setting, promoting a...
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Dayton, Ohio, United States Travel Nurse Source Full timeJob Title: Travel Nurse RN Opportunity with Titan Medical GroupJob Type: TravelerShift: Night (3x12)Certifications: ACLS/BCLS/BLSAbout the Position:Titan Medical Group is seeking a dedicated and experienced Stepdown RN to join their team for a 13-week assignment. As a travel nurse, you will have the opportunity to work in a new and challenging environment,...
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Oncology Nursing Supervisor
1 week ago
Dayton, Ohio, United States Clinical Management Consultants Full timePosition OverviewA prominent healthcare facility is seeking an Oncology Nursing Supervisor to lead their inpatient medical oncology team. This role is pivotal in ensuring high-quality patient care within a supportive and collaborative environment.This esteemed health organization offers a comprehensive range of services, including Cancer Care, Emergency...
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Nursing - Traveling Healthcare Professional
19 hours ago
Dayton, Ohio, United States Jackson Nurse Professionals Full timeJackson Nurse Professionals is seeking a skilled travel nurse RN Home Health Hospice to fill a critical need in patient care.**Job Summary:**~ **Shift:** 8 hours, days~ **Employment Type:** Travel~ **Perks:** * Full Medical Benefits & 401k Matching Plan * Option for Same Day pay * Referral and Loyalty bonuses * Travel and certification...
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Clinical Nurse-CN-Supp
7 days ago
Dayton, United States Premier Health Partners Full timeREGISTERED NURSE PACU MVHN SURGERY CENTER 7A - 3:30P / PRN The Clinical Nurse-CN-Supp is a registered nurse (RN) who partners with and advocates for patients/families/significant others to provide physical, emotional and spiritual support which impacts patient outcomes in a safe environment. The RN functions in a versatile role that demonstrates...
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Ambulatory Nurse
3 weeks ago
Dayton, United States Dayton Children's Full timeFacility: Dayton Children's - Main CampusDepartment: Rheumatology/Allergy Clinic/Sleep ClinicSchedule: Part timeHours: 8Job Details: The Ambulatory Nurse is a nursing staff position, which reports to the Administrative Manager. Performs treatments, administers medications, assists procedures performed without anesthesia while utilizing aspectic technique,...
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Clinical Liaison
2 months ago
Dayton, United States Aventura Health Group Full timeAventura Health Group is seeking a Clinical Liaison for it's skilled nursing facility in the Dayton/Trotwood area to add to our Marketing/Clinical Team.The Clinical Liaison will be responsible for driving strategies for census development through cultivation of referral relationships, execution of marketing plans and patient assessment and...
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Travel Nurse
19 hours ago
Dayton, Ohio, United States Jackson Nurse Professionals Full timeJackson Nurse Professionals is seeking a skilled travel nurse RN for a challenging home health and hospice assignment in a dynamic healthcare setting.**Job Summary:**~ **Employment Type:** Travel~ **Shift:** 8 hours, days**Perks and Benefits:**• Full Medical Benefits & 401k Matching Plan• Option for Same Day pay• Referral and Loyalty bonuses• Travel...
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Ambulatory Nurse- Pulmonary Clinic
3 weeks ago
Dayton, United States Dayton Children's Full timeFacility: Dayton Children's - Main CampusDepartment: Pulmonary ClinicSchedule: Full timeHours: 32Job Details: The Ambulatory Nurse is a nursing staff position, which reports to the Administrative Manager. Performs treatments, administers medications, assists procedures performed without anesthesia while utilizing aspectic technique, assists with employee...
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Dayton, Ohio, United States Travel Nurse Source Full timeStepdown RN Opportunity with Triage StaffingTravel Nurse Source is partnering with Triage Staffing to find a qualified Stepdown RN for a 13-week assignment.About the PositionJob Title: Stepdown RNAssignment Type: Travel NursingBenefits of Travel NursingGain exposure to diverse patient populations and medical proceduresBroaden your clinical skills and enhance...
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Clinical Nurse
1 week ago
Dayton, Ohio, United States Premier Health Partners Full timePosition: Clinical Nurse - Progressive Care Unit 2 Mixed Acuity (Cardiac Advanced Care & Medical/Surgical)Schedule: Full Time / Night Shift / 72 Hours per pay periodThe Clinical Nurse serves as a vital member of the healthcare team, engaging closely with patients and their families to deliver comprehensive care that improves patient outcomes in a safe...