临床申诉护士（临时）
Clinical Appeals Nurse (PRN)
负责审查医疗记录并准备临床申诉，以应对医疗必要性拒绝和诊断相关组（DRG）重新分类
职责
- 针对管理式医疗组织、政府机构和回收审计承包商（RACs）对医院客户的拒绝，准备并提交临床申诉
- 审查医疗记录，利用行业指南、医疗保险政策和最佳实践标准来支持申诉论点
- 参与行政法官（ALJ）听证会，口头陈述以支持医疗保险拒绝的撤销
- 分析拒绝模式，并提供见解以帮助减少未来的拒绝
- 与申诉团队和医院客户合作，提供申诉状态和结果的更新
- 保持对医疗保健法规、编码指南和与申诉流程相关的保险方政策的最新了解
资格要求
必需条件
- 护理学理学学士（BSN）或同等学位
- 有效的无限制注册护士执照
- 至少5年在急性护理环境中的临床经验
- 至少3年在病例管理、使用审查或临床申诉方面的经验
- 出色的书面和口头沟通能力
- 熟练使用微软办公套件，特别是Word和Excel
- 强大的分析和解决问题的能力，注重细节
优先考虑
· 具有保险方病例管理或医疗总监级审查的经验
期望
· 能够适应远程工作安排和虚拟协作工具
- 可能需要偶尔出差参加研讨会、客户会议或现场听证会
- 身体需求包括长时间坐着、使用电脑和电话沟通
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查看英文原文
Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and diagnosis-related groups (DRG) reassignmentsResponsibilities
- Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients
- Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments
- Participate in Administrative Law Judge (ALJ) Hearings, presenting oral arguments to support the reversal of Medicare denials
- Analyze denial patterns and contribute insights to help reduce future denials
- Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes
- Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process
Qualifications
Required
- Bachelor's of Science in Nursing (BSN) or equivalent degree
- Current and unrestricted RN license
- At least 5 years of clinical experience in acute care settings
- At least 3 years of experience in case management, utilization review, or clinical appeals
- Exceptional written and verbal communication skills
- Proficiency with MS Office suite, particularly Word and Excel
- Strong analytical and problem-solving skills with attention to detail
Preferred
· Experience with payer-side case management or medical director-level review
Expectations
- Comfortable with remote work arrangements and virtual collaboration tools
- May require occasional travel for conferences, client meetings, or in-person hearings
- Physical demands include extended periods of sitting, computer use, and telephone communication
Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.
Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.
If you are located in a state which grants you the right to receive information on salary range, pay scale, description of benefits or other compensation for this position, please use this form to request details which you may be legally entitled.
All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.
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Originally posted on Himalayas