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Medical Appeals Review Nurse

Job Attributes

Job Id:

16049

Job Category:

Clinical & Life Sciences

Job Location:

Glen Burnie, MD  21060

Security Clearance:

Not Defined

Business Unit:

Piper Companies

JOB DESCRIPTION

 

Piper Clinical Solutions is seeking a motivated Medical Appeals Review Nurse in Baltimore, MD to support a local health system with utilization management and coordination activities with outside hospitals.

Responsibilities for the Medical Appeals Review Nurse:

  • Responsible for the utilization management and review of inpatient and outpatient services for assigned EHP, Tri-care, DoD, and Priority Partners incoming claims
  • Responsible for secondary assessments of individual cases and making determinations for medical necessity
  • On-site concurrent and post-pay review, clinical management, and care coordination
  • Issue reports reflecting inpatient variances
  • Communication with inpatient and outpatient medical review teams to explain determinations
  • Gaining new information for claims in the form of physician notes, medical history, and justification of services
  • Weekly meetings with Medical Directors from assigned hospital locations to assess denials
  • Responsible for discharge planning for certain patient cases
  • Conduct root cause analysis to identify, monitor, and create measurable trends for re-admission levels

Requirements for the Medical Appeals Review Nurse:

  • 3+ years of nursing experience in an acute care hospital setting
  • Experience with utilization review or appeals review
  • Experience with utilization management review and affiliated legal and medical issues
  • Current RN licensure in Maryland
  • Associate’s degree in Nursing required

 

Compensation for the Medical Appeals Review Nurse:

 

  • Salary based on meeting of requirements
  • Full Benefits: Health, Dental & Vision Insurance, PTO, Paid Holidays, and 401K

 

 

Keywords:

 

Utilization review, registered nurse, milliman, interqual, ICD-9, ICE-10, CPT, HCPCS, DRG, APC, CPT, pre-pay, acute care, health insurance, health plan, health care, medical review, nurse, manager, intake, outpatient, medical review, home care, RN, CCM, Certified case manager, case management, medicare, medicaid, advance med, aerial, cms, tri care, healthsuite, advantage md, ushfp, ehp, priority partners, hospital, discharge planning, ARIEL, appeals, medical appeals review

 

 

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New Search

Job Id:

16049

Job Category:

Clinical & Life Sciences

Job Location:

Glen Burnie, MD  21060

Security Clearance:

Not Defined

Business Unit:

Piper Companies