1 clinical reviewer utilization management jobs found

Job Summary :  The Clinical Appeals Specialist is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Clinical Appeals Nursing Specialist will write sound, compelling factual arguments in order to recoup revenue.    This position also facilitates collaboration between the Utilization Review Specialist's, Medical Staff, Physician Advisor, Nursing staff, Commercial Payers, VA, Managed Medicare Organizations, Medicare, and Medicaid (Center for Medicare/Medicaid Services) to ensure correct admission status as dictated by medical necessity criteria for correct reimbursement for level of care provided and to ensure that any denial is thoroughly reviewed and that an appeal letter, if warranted, is well written and submitted in a timely manner.   In addition, the following are essential duties and responsibilities of the Nurse Reviewer:...