Summary
We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.
Your role in our mission
- Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
- Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
- Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
- Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
- Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
- Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
- Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
What we’re looking for
- Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
- Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) preferred
- 5+ years clinical experience or 5+ years medical record coding experience preferred
- Working knowledge of the appeals and hearings process
- Experience using MCG or InterQual criteria preferred
- Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
- Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions.
- Ability to multi-task in a fast-paced production environment.
What you should expect in this role
- Remote (Work from Home)
- Up to 25% Travel for onsite hearing testimony
Applications for this posting will be accepted until November 25, 2025.