[New Job Opening] Registered Nurse – Appeals Nurse job Vacancy in Remote

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Registered Nurse – Appeals Nurse
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Description : EXCITING JOB OPPORTUNITY with a rapidly growing organization. This role is an amazing opportunity to grow and diversify your career within the healthcare arena.ABOUT THE COMPANY: ProPeer is dedicated to connecting quality physicians with the outcome needs of our partners in the health and legal industries. The heart of our drive for quality and excellence rests in our unflinching integrity; we bend over backwards to provide the best possible service but will never bend our integrity. ProPeer realizes that behind the paperwork and reports, there are people, mothers, fathers, sisters, brothers, sons, and daughters. These are people in need of the best, most accurate, medical care possible and we are tasked with ensuring they receive it in a cost-effective manner. We offer competitive compensation and fantastic benefits, as well as a professional workplace in a business casual dress environment. You’ll also find plenty of options for professional development and advancement with us as this position allows you to come in and learn our unique approach at offering healthcare cost management solutions. If this sounds like the kind of career move you’ve wanted to make, and if you meet our qualifications, we want to talk with you!WHAT WE LOOK FOR: Ideal candidate is a highly motivated and dynamic individual that thrives in a fast-paced environment.Job Summary: The Appeals Nurse position supports the Independent Review Organization (IRO) in quality assurance efforts of commercial health non-appeal, internal appeal, state external appeal and Federal PPACA appeal cases. All Appeals Nurses are responsible for conducting quality assurance checks to include analyzing of medical records, prior denials, ensuring proper clinical specialty is utilized for reviews, and appropriate evidence-based literature is used in support of rationale. Additionally, the Appeals Nurses ensure that details of the patient’s condition, physician orders, course of treatment and well supported rationale are present within the clinical reviewer’s final review.Major Duties and Responsibilities: · Comprehension of medical/surgical modalities and imaging techniques· Ability to analyze clinical documentation, prior denials and supporting documentation to ensure the quality of the clinical reviewer’s final review· Audit and analyze patient records to ensure quality patient care and appropriateness of services· Utilize pre-approved criteria/guidelines and plan language to validate medical necessity/appropriateness of treatment (e.g. Policy Plan Language, Milliman Care Guidelines, Interqual)· Ability to understand and analyze plan language documentation· Understanding of proper citation of evidence-based literature and requirements of clientsKeeps current with regulation changes· Perform a low to moderate amount of research on a case by case basisConducts audit to ensure a high-quality, professional report free of grammar and spelling errors is delivered to the client· Communicate with physician reviewers to address/correct errors or omissions and to investigate questionable claims· Responsible for amending reports when necessary with any additional clinical information provided· Participates in an interdisciplinary health care team to achieve positive outcomes· Ability to complete average daily case load of 15-20 cases once released from training· Requires regular and consistent attendance· Other duties as assignedKnowledge and Abilities Requirements: Knowledge of Basic Anatomy· Comprehension of medical/surgical modalities and imaging techniquesAbility to analyze clinical documentation in relation to utilization reviews· Ability to Interpret and apply appropriate guidelines to utilization reviews· Ability to use logic and reasoning to determine and utilize appropriate evidence-based guidelinesAbility to read, analyze, and interpret documents, reports, technical procedures, governmental regulation, and correspondence.Ability to write routine reports and correspondence; and ability to present information in one-on-one, small group, and large group situations to management and staff.Ability to apply proper grammar, spelling, punctuation, and format to typed material.General Typing Skills at 45wpmAbility to use Microsoft products, Word, Excel, PowerPoint, OutlookPerform various computer functions to include saving, copying, pasting, scrolling, etc.High level of oral and written communication skills with a demonstrated ability to deliver excellent customer serviceInteract professionally and effectively with physician reviewers, staff, and clients from all departments within and outside the Company.Demonstrated ability to work cross-functionally to solve complex problems and improve quality and serviceMust have a track record of producing work that is highly accurate, demonstrating attention to detailBuild professional relationships that support the brand and its imageAbility to multi-task and quickly adapt in a fast-paced environmentMaintain a positive attitude and outstanding customer service while working closely internally with Nexus team-members, panel physicians and clients.Strong organizational skillsAttention to detailProficiency in English with an aptitude for spelling and grammarExemplary planning and time management skillsAbility to multi-task, prioritize, and work in high pressure, deadline driven environment· Demonstrated ability to problem solve complex, multifaceted, situations· Ability to engage easily in abstract thought· Strong organizational and task prioritization skillsEducation/Credentials: RN with 1- 3 years of experience in Managed Care settingProficient computer skills; able to navigate through multiple software systems; knowledge of Microsoft Word, Excel, and OutlookThis job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.Job Type: Full-timePay: $25.00 – $35.00 per hourBenefits:401(k)401(k) matchingDental insuranceDisability insuranceEmployee assistance programHealth insuranceLife insurancePaid time offReferral programVision insuranceSchedule:8 hour shiftMonday to FridayEducation:Associate (Required)Work Location: Remote
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