Contract Clinical Appeals RN

4 days ago

Houston, Texas, United States Sutherland Full time $104,000 - $156,000 per year
Company Description

We are One Sutherland — a global team where everyone is working together to create great breakthrough solutions. Our workforce has thrived in an environment of diversity of thought, experience and background. We celebrate our diversity and embrace it whole-heartedly. Sutherland is an equal opportunity employer. We promote a positive work environment by conducting ourselves professionally and helping each other achieve our goal of One Sutherland Team, Playing to Win.

Job Description

The Appeals Nurse will review medical records to construct compelling clinical appeals in order to overturn managed care denials based upon clinical nursing judgment and the medical necessity of services delivered.

Duties and Responsibilities:

  • Review of medical records to evaluate the validity of 3rd party denials.
  • Assess strength of completed appeal to predict favorable outcomes.
  • Ability to detect issues resulting in denials and constructively report on issue to assist in resolution.
  • Construct 1st and 2nd level appeals by applying clinical rationale.
  • Manage assigned workload of accounts so appeals are submitted timely in accordance with payer timeframes.
Qualifications
  • Licensed RN.
  • 5 years experience working in acute hospital setting.
  • Knowledge of managed care and utilization review process.
  • Knowledge of Interqual criteria and/or Milliman Guidelines.
  • Knowledge of DRGs.
  • Excellent written skills.
  • Proficient computer skills including Microsoft Office, with access to high-speed internet.
  • Experience as a Case Manager or UR nurse who has written appeals is required.
Additional Information

This role does not offer an hourly rate. Payment is a 1099 paid bi-weekly upon Reviews. We will pay $50 per Appeal, and $25 per Review if cannot be appealed. You will also be paid $25/hour for any IT/ Compliance trainings that require completion of your time.

All your information will be kept confidential according to EEO guidelines.

EEOC and Veteran Documentation
During employment, employees are treated without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status.
At times, government agencies require periodic reports from employers on the sex, ethnicity, handicap, veteran and other protected status of employees. The purpose of this Administrative EEO Record is for statistical analysis only and is used to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of the Administrative EEO record is optional. If you choose to volunteer the requested information, please note that all 
Administrative EEO Records are kept in a Confidential File and are not part of your Application for Employment or Personnel file.
Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

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