Clinical Appeals RN - Commercial reputed company - Remote in US

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 together You'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

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications:

• 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

Preferred Qualifications:

• 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

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes - an enterprise reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Apply tot his job Apply To this Job