Employer Industry: Healthcare Services

Why consider this job opportunity:
- Opportunity for career advancement and growth within the organization
- Comprehensive benefits package including subsidized health plans, life insurance, and 401(k) retirement savings plan with company match
- Paid annual leave that increases with tenure, plus nine paid holidays
- Access to on-site cafeterias and fitness centers in major locations
- Continuing education funds for additional certifications and certification renewal
- Remote work opportunity with a full-time schedule (Monday-Friday, 8am-5pm)

What to Expect (Job Responsibilities):
- Conduct thorough research and documentation of appeal or retrospective review requests in compliance with regulations and standards
- Perform clinical reviews of service appeals based on documentation, contractual requirements, and policies while ensuring confidentiality
- Analyze and determine the application of policies and procedures to clinical information during appeal and retrospective reviews
- Participate in special projects aimed at identifying quality of care issues through clinical information reviews
- Document decisions within mandated timeframes to ensure compliance with applicable standards

What is Required (Qualifications):
- Required Education: Associate Degree in Nursing or Graduate of an Accredited School of Nursing
- Minimum of two years of clinical experience plus one year in utilization/medical review, quality assurance, or home health, OR three years of clinical experience
- Active, unrestricted RN license from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
- Strong clinical experience in home health, rehabilitation, and/or broad medical-surgical settings
- Working knowledge of managed care and various healthcare delivery systems

How to Stand Out (Preferred Qualifications):
- Experience with Medicare appeals processing and claims review
- Familiarity with the Administrative Law Judge (ALJ) process
- Knowledge of statistical principles and quality assurance standards
- Understanding of National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) guidelines
- Knowledge of Health Insurance Portability and Accountability Act (HIPAA) standards/regulations

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