Sutherland
Job Description
The Appeals Nurse will review medical records to construct compelling clinical appeals in order to overturn managed care denials based on clinical nursing judgment and medical necessity of services delivered. The role is contract and paid 1099 bi‑weekly. You will receive $50 per appeal, $25 per review if not appealable, and $25 per hour for IT/compliance training.
Duties and Responsibilities
Review medical records to evaluate the validity of third‑party denials.
Assess the strength of completed appeals to predict favorable outcomes.
Detect issues that result in denials and constructively report them to aid resolution.
Construct first and second level appeals by applying clinical rationale.
Manage assigned workload so appeals are submitted timely in accordance with payer timeframes.
Qualifications
Licensed RN.
5 years experience working in an 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 and high‑speed internet.
Experience as a Case Manager or UR nurse who has written appeals is required.
Equal Opportunity Employer All information will be kept confidential in accordance with EEO guidelines. The company is an equal opportunity employer.
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Duties and Responsibilities
Review medical records to evaluate the validity of third‑party denials.
Assess the strength of completed appeals to predict favorable outcomes.
Detect issues that result in denials and constructively report them to aid resolution.
Construct first and second level appeals by applying clinical rationale.
Manage assigned workload so appeals are submitted timely in accordance with payer timeframes.
Qualifications
Licensed RN.
5 years experience working in an 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 and high‑speed internet.
Experience as a Case Manager or UR nurse who has written appeals is required.
Equal Opportunity Employer All information will be kept confidential in accordance with EEO guidelines. The company is an equal opportunity employer.
#J-18808-Ljbffr