Clinical Appeal Nurse
4 days ago
Clinical Appeals Specialist is responsible in writing a compelling and effective appeal based on the clinical Documentation, payer-specific policies and is compliant to Federal and State policies. The Clinical Appeals Specialist is responsible for appeals and follow-up on clinical denials, providing appropriate denial information to be submitted to departments to ensure systems, processes and measures of effectiveness are created and implemented to resolve root cause issues and reduce/ eliminate denials. The Clinical Appeals Specialist ensures that appeals are submitted in a timely manner.
Responsibilities:
- Performs medical record reviews concurrently and/or retrospectively and be able to determine why cases are denied and whether an appeal is required.
- Able to review clinical denials in a timely manner and appropriately utilizing clinical criteria sets such as of InterQual criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal
- Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medically necessary services denied for no authorization.
- Able to write an effective and efficient appeal based on clinical documentation and payer specific policies and client-specific instructions.
- Able to think critically and able to use clinical judgment in providing effective and well supported appeals.
- Maintains thorough and current knowledge in clinical expertise and stay relevant in the fast changing trends in healthcare, reimbursement methodologies and utilization. Able demonstrate basic patient accounting knowledge i.e., UB04 claim form and Explanation of Benefits ("EOB") components, adjustments, credits, debits, balance due, patient liability, etc.
- Able to read and understand medical abstract information from handwritten to type written medical record.
- Demonstrates proficiency in utilization of electronic tools and competency in Microsoft Office.
- Able to observe specific payer guidelines for appeal submission and ensures compliance to law and regulations.
- Other tasks/functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirement of your position and our business.
Qualifications:
- Bachelor of Science in Nursing graduate
- Must be Registered Nurse
- Strong writing and grammatical skills
- Above average written and verbal communication skills
- Demonstrates proficiency in the application of medical necessity criteria.
- Ability to conduct intensive research regarding State/Federal guidelines and other regulatory processes.
- Excellent communication skills in verbal and professional letter writing skills.
- Able to think critically.
- MS Office proficient
- Ability to multi-task.
- Ability to work with minimal supervision and able to work under pressure within the given timeframe.
- Self-motivated, customer-oriented and a strong team player
- Must be a team player, and can also work independently, with minimal supervision
Job Type: Full-time
Work Location: Remote
-
Clinical Appeals Nurse
2 days ago
Work from Home, Philippines Coronis Health LLC Full time ₱1,200,000 - ₱2,400,000 per yearJOB SUMMARY:The Clinical Appeals Nurse is responsible for creating a convincing and effective appeal based on clinical documentation, payer-specific standards, and compliance with federal and state policies. The Clinical Appeals Nurse is responsible for clinical denial appeals and follow-up, providing appropriate denial information to departments to ensure...
-
Quality Assurance Nurse
4 days ago
Work from Home, Philippines Frontline Medical Group, LLC Full time ₱336,000 per yearJob Summary:The Quality Assurance Nurse is tasked with ensuring that all clinical operations within the Company maintain the highest standards of quality, safety, and reliability. This role ensures that the agency's clinical practices are continually improving and meeting all regulatory standards.Key Responsibilities:Conduct audits and quality checks to...
-
Telephone Triage Nurse
2 days ago
Work from Home, Philippines Virtual Staffing Solutions Full time ₱1,200,000 - ₱2,400,000 per yearDescriptionThe Emergency Triage Nurse plays a critical role in assessing and managing urgent patient concerns in a fast-paced aesthetics clinic. This nurse provides immediate clinical evaluation, prioritizes care needs, and ensures safe, timely intervention for post-procedure complications, adverse reactions, or unexpected symptoms.Key ResponsibilitiesRapid...
-
Work from Home, Philippines Complete Care Management Services -ACO Full time ₱375,000 - ₱450,000 per yearJob Title: Clinical ReviewerLocation: Philippines (Work from Home)Job Description:We are actively seeking a detail-oriented and experienced Clinical Reviewer to join our team in the Philippines. The Clinical Reviewer will play a crucial role in evaluating and ensuring the quality and compliance of clinical documentation. If you have a strong clinical...
-
Remote Triage Support Nurse
2 days ago
Work from Home, Philippines Texas App Consulting Services Full time ₱384,000 - ₱480,000 per yearJob Title: Remote Triage Support Nurse (Non-Clinical, Philippines-Based)Company: Texas APP Consulting Services LLCJob Type: Full-time, Remote (Work From Home)About the RoleTexas APP Consulting Services LLC is seeking experienced Filipino Registered Nurses to provide 24/7 non-clinical triage support to our U.S.-based clients. This role is fully remote,...
-
WFH | Clinical Educator
4 days ago
Work from Home, Philippines Dextra Outsourcing Solutions, Inc Full time ₱360,000 - ₱420,000 per yearJob Description: Clinical EducatorPosition Overview:Clinical Education Coordinator is responsible for assisting in instructing the staff and referring entities of our client. The CEC will devise curriculum from evidenced-based research within the practice under the guidance of the Clinical Education Manager. The CEC will collaborate and assist in...
-
Medical Virtual Nurse
4 days ago
Work from Home, Philippines Staffing For Doctors Full time ₱800,000 - ₱1,200,000 per yearAbout the Role:Staffing for Doctors is looking for a qualified Medical Virtual Nurse to provide exceptional telehealth services to our patients. As a Medical Virtual Nurse, you will be responsible for delivering high-quality nursing care through virtual platforms, assisting patients with their health concerns, and providing education and support in a...
-
Medical / Clinical Coder
4 days ago
Work from Home, Philippines Seven Seven Global Services Inc Full time ₱600,000 - ₱800,000 per yearData assessment & schema finalization efforts for different markets.Create and maintain Schemas and Properties to fill in for the coding gaps across different clinical domains.Annotations - Analyse and interpret claims header level & line level descriptions and other documentation, categorize them into clinical domains (E.g., Procedures, radiology, Nursing...
-
Clinical Denials Specialist
4 days ago
Work from Home, Philippines Coronis Health LLC Full time ₱80,000 - ₱120,000 per yearClinical Denial Representative is responsible to review patient's medical claim when resolving edits for compliance (prior billing) and issues on rejections(rejected by the payor) in the physician side. Clinical Denial Representative must understand and comply with federal and state coding and billing regulation. The Clinical Denial Representative must...
-
Clinical Intake Coordinator
4 days ago
Work from Home, Philippines Cliniqon Full time ₱420,000 - ₱540,000 per yearCliniqon is an organization that promotes a safe, inclusive work environment and prioritizes employees' well-being while creating a haven for clients and customers and their much-deserved experiences.Join Our Growing and Winning TeamCliniqon is hiring HOME HEALTH CLINICAL INTAKE COORDINATORSQualifications:Home Health background is a mustMust be a Registered...
