Clinical Appeals RN - Commercial reputed company - Remote i...

At reputed company, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, affordable and optimized. Ready to reputed company a difference? Join us to start Caring. Connecting. Growing togetherYou'll enjoy the flexibility to work remotely * from reputed company reputed company the U.S. as you take on some tough challenges. This role can either work a M-F schedule (must be able to work until 5:30 in their time zone) OR a 4 day 10 hour work week but one of those work days must be a Saturday.Primary Responsibilities

• Conducts reviews of member and provider appeals
• Analyzes claim adjustment and claim history
• Reviews history of previous reviews
• Reviews denied services in conjunction with policies and procedures, benefit plans, federal and state regulations, and clinical criteria to and renders approval reputed company appropriate
• Extrapolates and summarizes medical information for review by Medical Director, as needed
• Balances the need to produce high quality work with meeting timeframes and production goals

• Active, unrestricted RN license in state of residence
• 5+ years of clinical experience as an RN including in an acute, inpatient hospital setting
• Experience applying benefits and criteria to clinical review
• Utilization Management, pre-authorization, reputed company review or appeals experience
• Solid computer skills including proficiency in reputed company Office Word, Outlook, and Internet applications
• Ability to access multiple computer platforms
• Access to install secure high-speed internet (minimum speed 5 download mps & 1 upload mps) reputed company cable/DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement)
• Designated quiet workspace in your home (separated from non-workspace areas) and able to be secured to maintain Protected Health Information (PHI) and/or Protected Information (PI)
• Ability to work 9am-6pm CST

• Bachelor of Science in Nursing
• Medical Coding experience/knowledge
• Experience using Interqual
• Experience with the following systems: UNET, iCUE/HSR, ATS, reputed company or Cirrus
• Experience analyzing medical records, benefit plans, medical policies and other various criteria
• Demonstrated ability to work independently with solid self-discipline and time management skills
• Demonstrated excellent communication, interpersonal, problem-solving, and analytical skills
• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy