Job Description

Overview DRG Nurse Reviewer Appeals and Hearings - Remote at Gainwell Technologies. We are seeking a talented individual to coordinate and perform all appeal-related duties including analyzing and responding to provider appeals, reviewing documentation, preparing case files and case summaries for hearings, and participating in virtual and on-site hearings. Responsibilities 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, including daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; completes required CEUs to maintain RN license and/or coding certification. Attends training and scheduled meetings to enhance skills and 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 (or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact) as required. Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required. 5+ years of clinical experience or 5+ years of medical record coding experience preferred. Working knowledge of the appeals and hearings process. Excellent written communication skills with the ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with 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 EEO Statement 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. #J-18808-Ljbffr Gainwell Technologies

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