Registered Nurse
3 weeks ago
Job Summary: Talent Software Services is in search of a Registered Nurse for a contract-to-hire position that can be worked 100% remotely.
Primary Responsibilities/Accountabilities:
- Our Appeals Nurse will examine 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
In addition, this role will: - Utilize clinical knowledge and clinical review judgment to conduct medical review of claim documentation for first-level appeal cases
- Provide clear and concise written explanations for reason a specific claim or set of claims cannot be paid as a result of first-level redetermination
- Work with and provide direction to Redetermination Representatives to assure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards
- Analyze appeals and identify specific high-volume problem issues and relay information to Redeterminations Manager and Senior Analyst
- Participate in various workgroups for purposes of Continuous Quality Improvement (CQI) to promote consistent medical review of claim documentation and information
- Collaborating with a team of clinicians and non-clinicians
- Learning a variety of systems, including but not limited to, the Medicare Appeal System (MAS) which is a content management system for Part A appeals and our Hyland OnBase tool which is our content management system used for Part B appeals
- Experience working in an environment that serves our nation's military, veterans, Guard and Reserves, and Medicare beneficiaries
- Working in a continuous performance feedback environment
Qualifications:
- Associate's (ASN) or Bachelor's Degree in Nursing (BSN)
- Active RN license, applicable to state of practice in good standing
- Have moved away from direct patient care and want to continue using your nursing knowledge in a new and different way
- Excel at analyzing information and critical thinking to make sound medical decisions
- Are highly organized and adept at researching and finding answers independently using all available resources
- Thrive in a production environment where quality and production metrics are critical to individual and team success
- Have strength in technical writing
- Desire day hours with no on-call work and holidays off
- Are technically strong on computers including MS Outlook, Teams, OneNote, Word, and Excel
- Are self-motivated and work with a great degree of independence
- Are looking for a full-time, permanent position
Preferred:
- Experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals
- Strong technical writing skills
- Strong computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.
- 4 or more years of experience in clinical nursing
- Experience outside of direct patient care.
- Experience working with Medicare Part A and Part B
- Previous experience working for another Medicare Administrative Contractor (MAC)
- Experience working in a remote work environment
If this job is a match for your background, we would be honored to receive your application
Providing consulting opportunities to TALENTed people since 1987, we offer a host of opportunities including contract, contract to hire and permanent placement
Let's talk
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