Employer Industry: Health Insurance and Government Contracting

Why Consider this Job Opportunity:
- Salary up to $68,000
- Opportunity for career advancement and growth within the organization
- Remote work option available
- Performance bonus and/or merit increase opportunities
- Competitive paid time off
- Health insurance, dental insurance, and telehealth services start DAY 1

What to Expect (Job Responsibilities):
- Utilize clinical knowledge and clinical review judgment to conduct medical review of claim documentation for first-level appeal cases
- Provide clear and concise written explanations for reason a specific claim or set of claims cannot be paid as a result of first-level redetermination
- Work with and provide direction to Redetermination Representatives to assure all redeterminations are responded to within CMS quality and timelines standards
- Analyze appeals and identify specific high-volume problem issues and relay information to Redetermination Manager and Senior Analyst
- Participate in various workgroups for purposes of Continuous Quality Improvement (CQI) to promote consistent medical review of claim documentation and information

What is Required (Qualifications):
- Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN)
- Active RN license, applicable to state of practice in good standing
- Experience working in Medical Management, Medical Review, Utilization Management/Review, or Appeals
- Strong technical writing skills
- Strong computer skills with experience working in multiple online systems including MS Outlook, Teams, OneNote, Word, and Excel

How to Stand Out (Preferred Qualifications):
- 4 or more years of experience in clinical nursing
- Experience working with Medicare Part A and Part B
- Previous experience working for another Medicare Administrative Contractor (MAC)
- Experience working in a remote work environment

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