Clinical Appeals RN

Clinical Appeals Auditor | Responsibilities and Metrics

Are you looking for your next challenge? The Virtual Business Office Associates is the perfect balance of a diverse and growing workforce that still feels like home. If you are an A/R Specialist with experience working denied claims from beginning to end, come join our best in KLAS Extended Business Office today...

Hiring remotely from: FL, GA, TX, NC, SC, VA, KY, AL.

FLSA Status: Exempt

What’s in it for you:
• Add to your portfolio by joining our fast-paced, exciting, diverse and inclusive work environment
• Endless growth opportunities and continuous professional development
• You’ll support one of the largest professional services firms in the world, with access to cutting edge automation and AI technologies to enhance your workday experience
• A permanent position with our company that offers stability and growth opportunities
• A flexible schedule that allows you to enjoy a work life balance, and leave early on Friday’s
• Use the latest EMR systems and utilize full portal access for the insurance payers worked
• Comprehensive employee benefits

What you’ll do:
• Manages denials and appeals in a manner that diligently investigates every unpaid claim
• Assesses the need for formal appeals of all clinical denials
• Appeals the rejections appropriately as per the appeals process for the provider contract
• Reviews and audits clinical documentation to ensure its sufficiency
• Utilizes various resources in order to understand the appeals and denials criteria; searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable
• Adheres to all appeal timelines as prescribed by payer agreements
• Employs the use of different systems to evaluate clinical and financial data
• Uncovers trends related to different cases and various insurance carriers; maintains related data and monitors payer response to appeal activity
• Provides information to leadership on patterns or trends associated with denials and appeals

What you’ll need:
• Minimum Degree: Bachelor’s degree or higher in nursing; current RN licensure
• Minimum Years of Experience: 5+ years of experience in a clinical and business setting
• Software/Systems Experience: Interqual and/or Milliman

Recruiting Solutions and Virtual Business Office Associates provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Recruiting Solutions and Virtual Business Office Associates comply with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.

Recruiting Solutions and Virtual Business Office Associates expressly prohibit any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status.

Job Type: Full-time

Pay: $85,000.00 - $95,000.00 per year

Benefits:
• 401(k)
• Dental insurance
• Flexible schedule
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Standard shift:
• Day shift

Weekly schedule:
• Monday to Friday

Experience:
• Appeals: 3 years (Preferred)

License/Certification:
• RN License (Preferred)

Work Location: Remote

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