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Clinical Appeals Specialist
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Job Description
- Req#: JR-100545
Employer Industry: Healthcare Services
Why consider this job opportunity:
- Opportunity for career advancement and growth within the organization
- Flexible work options, including full-time remote work or part-time in-office arrangements
- Engaging work environment focused on collaboration and professional development
- Chance to make a positive impact on patient care and organizational policies
- Comprehensive benefits package, including health insurance and retirement plans
What to Expect (Job Responsibilities):
- Review medical records to gather information for appeal correspondence and analyze clinical denials
- Collaborate with government agencies and third-party payers regarding audits and appeals
- Prepare and present professional presentations on audit and appeal data
- Conduct retrospective reviews of hospital records to assess appropriateness of care documentation
- Participate in various committees and quality improvement teams to enhance organizational policies
What is Required (Qualifications):
- Licensure as a Registered Nurse in the State of Rhode Island or under the Nurse Licensure Compact agreement
- Bachelor's Degree in Nursing, Health Science, or Health Business; Master's Degree preferred
- Minimum of three years of relevant clinical and/or administrative experience, with two years in utilization review activities
- Working knowledge of level of care criteria and familiarity with state and federal regulations
- Strong organizational skills and the ability to make sound clinical judgments
How to Stand Out (Preferred Qualifications):
- Experience in medical/surgical nursing and utilization review
- Knowledge of government and commercial payer regulations
- Participation in professional development activities related to healthcare regulations
#HealthcareServices #NursingCareers #RemoteWork #CareerAdvancement #QualityImprovement
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