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Nurse Reviewer, Appeals and Hearings Specialist
2 months ago
We are seeking a highly skilled Nurse Reviewer, Appeals and Hearings to join our team at Gainwell Technologies LLC. As a key member of our team, you will be responsible for coordinating and performing all appeal-related duties, including analyzing and responding to appeals from providers, reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately, preparing case files and case summaries for hearings, and participating in virtual and on-site hearings.
Your Key Responsibilities- Review provider appeals and redeterminations using approved clinical and coding guidelines and document appeal determinations clearly and concisely.
- Analyze and review appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
- Prepare case files and case summaries for hearings and actively participate in hearings in conjunction with the Medical Director.
- Assist management with training new reviewers, including daily monitoring, mentoring, feedback, and education.
- Maintain current knowledge of clinical criteria guidelines and/or coding guidelines and successfully complete required CEUs to maintain RN license and/or coding certification.
- Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
- Actively cross-train to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
- Unrestricted RN license or Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) preferred.
- 5+ years clinical experience or 5+ years medical record coding experience preferred.
- Working knowledge of the appeals and hearings process, with emphasis on excellent written communication skills, including the ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
- Experience using MCG or InterQual criteria preferred.
- Ability to multi-task in a fast-paced production environment while providing clear communication around appeals and hearings.
- This is a full-time permanent regular salaried (W-2) employee position.
- Upward career advancement is possible and encouraged.
- Health (medical, dental, vision) and paid time off benefits start on day 1 of employment.
- Company match 401K and other benefits available within months of starting.
- Computer and other company-provided items.
- Monday through Friday work schedule.
- This position is fully remote, however, travel to appeals and court hearings are required when necessary.
- For all remote positions, employees' Broadband Internet connections should have a minimum speed of 24MBS download and 8MBS upload. Greater speeds will, of course, provide better performance.
- Video cameras must be used during all interviews, as well as during the initial week of orientation if hired.
