Remote DRG Appeals Review RN

Job Overview

  • Clinical License RN
  • State(s) Nationwide

About the job

Job Overview:

As a Clinical Appeals Review Nurse you will review and analyze denied/downgraded MS-DRG and APR-DRG accounts received from payers (e.g., Medicare, Commercial, and Third Party). Utilizing clinical and coding expertise, the Registered Nurse will render determination on whether the denied/downgraded account is appealable. The Clinical Appeals Review Nurse will provide an appeal letter based on current coding guidelines and clinical criteria, as well las track and trend denial root causes for the specific coding denials.

Founded in 1994 Managed Resources (MRI) in Long Beach California, MRI partners with clients nationwide to help them solve complex revenue cycle and compliance challenges. In our over 25 years of operations, MRI has had the pleasure of working with many of the most prestigious healthcare organizations and medical groups in the county that span from the Hawaiian Islands to the East Coast.

Please read the below description and apply if you meet the requirements and would like to hear more about this opportunity with Managed Resources.

Responsibilities

Ideal candidate will be able to:

  • Write clear and concise letters, handle necessary technical vocabulary, and organize difficult or complex information in an understandable and efficient manner
  • Prepare clear and concise audit reports
  • Serve as a liaison with third party payer and agencies regarding appeals to ensure optimal reimbursement, any other billing or payment issues, and ensuring issues are resolved
  • Develop recommendations to maintain efficient and effective processes
  • Identify coding and clinical documentation issues and provides proactive recommendations to clients
  • Identify problem accounts and escalates as appropriate
  • Update patient account record to identify actions taken on account
  • Responsible for favorable resolution of third-party payment denials, adverse determinations, medical necessity denials, payment discrepancies, and contract misinterpretations
  • Review whether DRG’s are assigned correctly and if all diagnosis and procedure codes are identified and documented

CERTIFICATIONS

  • Registered Nurse (RN) License is required
  • CCS Certification through AHIMA or CPC Certification is required
  • Graduate of an accredited College or University is required

QUALIFICATIONS

Ideal candidate will possess the following:

  • 5+ years of clinical experience in Hospital inpatient and outpatient departments
  • 2+ years of clinical appeals/denials writing experience
  • Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG accounts received from payers (e.g., Medicare, Commercial, and Third Party)
  • Experience with Interqual and Milliman Care Guidelines (MCG) along with payer specific medical guidelines and how to apply them in an appeal
  • Experience in a variety of Electronic Medical Records (EMR) Systems, i.e. 3M, Nuance
  • Excellent verbal and written communication skills
  • Excellent organizational skills with a strong focus on detail

BENEFITS

Benefits for full time employees include:

  • Medical, Dental, and Vision Insurance
  • 401k plus matching
  • Paid time off
  • Paid holidays
  • Fully remote work environment
  • Employer provided equipment
  • Monthly phone/internet reimbursement
  • Access to our CEU’s

Managed Resources is an Equal Opportunity Employer (EOE) M/F/D/V/SO

 

 

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