DRG Nurse Reviewer Appeals and Hearings- Remote Job at Gainwell Technologies LLC, Florida

ajB1MnBaUHRoTit5SGNveEE0bUpIc0R1
  • Gainwell Technologies LLC
  • Florida

Job Description

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

 

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 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

 

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

 

Gainwell Technologies  is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. 

Job Tags

Full time, Work from home, Flexible hours,

Similar Jobs

Sysco

CDL A Local Delivery Truck Driver Job at Sysco

 ...Flexibility overtime as required, weekends and holidays as business needs require. Preferred Requirements1 year customer delivery experience preferred. 6 months hand cart/hand truck experience preferred. 6 months Food and Beverage experience preferred. 2 years... 

Marriott International

Housekeeping Attendant Job at Marriott International

 ...POSITION SUMMARY Our jobs aren't just about giving guests a clean room and a freshly made bed. Instead, we want to build an experience that is memorable and unique. Our Guest Environment Experts are skilled in a wide range of housekeeping functions with responsibility... 

AEFIS

UI/UX Developer (Remote) Job at AEFIS

 ...skills and have a good understanding of usability and design concepts. SO WHAT CAN I EXPECT FROM THE JOB? Responsibilities Develop a great user interface based on product requirements Create high-quality, high-performancesource code Ensure usability, use... 

PESG Inc.

Customer Service Representative - Entry Level - Immediate Hire Job at PESG Inc.

 ...We are actively hiring Entry-Level Customer Service Representatives for immediate start. This role is perfect for individuals seeking customer service experience , paid training , and career growth in a fast-paced, people-focused environment. No prior experience... 

UTMB Health

Advanced Practice Provider, Obstetrics & Gynecology - Urogynecology (South Metro Houston) Job at UTMB Health

 ...Houston in Galveston, TX UTMB Health Uro Gynecology OBGYN Opportunity: The UTMB Department of Obstetrics and Gynecology is seeking a full-time Advanced Practice Provider (Nurse Practitioner or Physician Assistant) to join our Division of Urogynecology and Reconstructive...