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Appeals Case Manage RN

Prestige Staffing

This is a Full-time position in Atlanta, GA posted April 9, 2021.

Prestige Staffing is hiring for an Appeals Case Manager Nurse. Looking for someone with Case Management / Utilization Review background to assist us in appealing and overturning Medicaid and Medicare Advantage clinical denials. This is a Monday – Friday position from 7:00am -3:30pm. The job will be located downtown Atlanta once the pandemic is over however could be 100% remote for the right candidate and situation. In the meantime it is remote where the contractor must provide a computer or laptop, phone and quiet work space to conduct their work daily. Must be within a comfortable driving distance for any in person meetings once COVID has settled down without compensation for mileage. Pay is $30+ an hour depending on experience and education.

Duties:

  • Responsible for the utilization review and technical appeal of clinically related denials (concurrent and retro) achieving optimal financial outcomes for the hospital.
  • Expert utilization and application of InterQual and Milliman criteria. Represents facility providing formal appeals via letter and phone to managed care payers.
  • Appeal processes include but are not limited to review of utilization review, billing, coding, charging, and clinically related technical errors.
  • Creates and designs databases documenting clinical and technical denial information which can then be further analyzed.
  • Provides denial reports on a monthly, quarterly, and requested basis to the Care Management Department, Patient Financial Services, Managed Care Contracting, Revenue Cycle, and hospital leadership including the CEO.
  • Reports reflect hospital trends regarding patterns of denials and outcomes of appeals using a data driven approach.
  • Uses financial analysis to develop proactive strategies for denials reduction.
  • Coordinates activities and strategies with the Care Management Department, Patient Access, Billing, Managed Care, and Physician Advisors.
  • Expert knowledge of every current managed care contract, informing the Managed Care Contracting Department of patterns, trends and critical incidents related to payment denials.
  • Represents hospital in identification, negotiation, and problem solving in conjunction with the Managed Care Contracting Department.
  • Prioritizes assignments to avoid financial risk.
  • Serves as a financial resource to team.
  • Expert knowledge base regarding payer regulations and industry trends.

Requirements:

  • Able to pass a criminal background and drug test to include nicotine
  • Minimum of 3 – 5 years of varied hospital and Utilization Review experience.
  • 2+ years experience in insurance setting with focus on Managed Care (preferred).
  • Expert in database functions and spreadsheets.
  • Graduate of an accredited School of Nursing and have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board.
  • Certification as CCM, HIAA, HFMA and/or Inpatient Coding preferred
  • Used to working in a production environment with metrics to meet daily, weekly, monthly and quarterly.
  • Able to start work immediately

Interested and qualified candidates apply today or pass along to a friend. We pay referral fees.

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