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Gainwell Technologies
DRG Nurse Reviewer Appeals and Hearings- RemoteGainwell Technologies • Any city, FL, US
DRG Nurse Reviewer Appeals and Hearings- Remote

DRG Nurse Reviewer Appeals and Hearings- Remote

Gainwell Technologies • Any city, FL, US
30+ days ago
Salary
$90,000.00 yearly
Job type
  • Full-time
  • Remote
Job description

Summary

We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.

Your role in our mission

  • Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
  • Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
  • Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
  • Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
  • Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
  • Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
  • Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.

What we're looking for

  • Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
  • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required
  • 5+ years clinical experience or 5+ years medical record coding experience preferred
  • Working knowledge of the appeals and hearings process
  • Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
  • Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions.
  • Ability to multi-task in a fast-paced production environment.

What you should expect in this role

  • Remote (Work from Home)
  • Up to 25% Travel for onsite hearing testimony

This position is for pipeline purposes, and we welcome applications on an ongoing basis.

The pay range for this position is $90,000.00 - $99,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
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DRG Nurse Reviewer Appeals and Hearings- Remote • Any city, FL, US

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