- St. Luke's University Health Network (Allentown, PA)
- …and/or formal meetings with auditor or payor representatives in defense of coding appeals , as needed. + Maintain necessary audit/appeal activity documents ... patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient...and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals… more
- CVS Health (Lansing, MI)
- …with heart, each and every day. **Position Summary** CVS Aetna is seeking a dedicated ** Appeals Nurse Consultant** to join our remote team. In this role, you ... critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical...+ This position may support UM (includes expedited), MPO, Coding , or Behavioral Health appeals . + This… more
- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory ... a case for determination, interacting directly with providers to obtain additional clinical information, and with members or their advocates to understand the full… more
- Northwell Health (Melville, NY)
- …+ Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect ... serves as a resource for the Health System. Reviews denial trends and identifies coding issues and knowledge gaps. Job Responsibility + Serves as liaison between the… more
- McLaren Health Care (Mount Pleasant, MI)
- …outcomes and fulfills the obligation and responsibilities of the role to support the clinical team. 3. Collaborates with the Denials Appeals RN to ensure payer ... + Certified Medical Coder, Certified in Healthcare Compliance, Certified Coding Specialist, or Certified Clinical Documentation Specialist certifications more
- Hartford HealthCare (Farmington, CT)
- … appeals for DRG denials, ensuring appeals are well-supported with clinical evidence, coding guidelines, and regulatory requirements. . Work closely with ... to DRG (Diagnostic Related Group) downgrades. This role involves validating the coding and clinical accuracy, ensuring proper documentation and collaborating… more
- Fairview Health Services (St. Paul, MN)
- …Reviews and analyzes medical records and coding guidelines to formulate coding arguments for appeals and/or coding guidance for potential ... critical research and timely and accurate actions including preparing and submitting appropriate appeals or re-billing of claims to resolve coding denials to… more
- Elevance Health (OH)
- …for employment, unless an accommodation is granted as required by law. The **Lead Clinical Review Nurse ** is responsible for serving as a team lead for ... with clinical reviewers and/or medical directors to ensure appropriate coding assignment. + Collaborates with providers to verify correct DRG assignment aiding… more
- Molina Healthcare (NE)
- …Medical Review Nurse provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory ... our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals experience. The candidate must have strong organizational… more
- Childrens Hospital of The King's Daughters (Chesapeake, VA)
- …defense, LifeNet and special focus audits and reports findings. + Serves as a clinical resource for coding / denial management and customer service issues. + ... + GENERAL SUMMARY + The Revenue Integrity Nurse Auditor is responsible for the auditing and...supporting documentation, as well as facilitates the completion of appeals in a timely manner. + Prepares trend and… more
- Garnet Health (Middletown, NY)
- …Garnet Health Medical Center. Responsibilities Under the direction of The Administrator, Coding & Clinical Documentation Improvement and Patient Access, the ... knowledge, required* Exceptional ability to communicate effectively with physicians and other clinical professional staff.* Knowledge of DRG and Coding appeal… more
- Minnesota Visiting Nurse Agency (Minneapolis, MN)
- **12/2/2025 - REVISED FTE *_SUMMARY:_* We are currently seeking a*Staff Nurse *to join our Utilization Management department for the/Emergency Department / This ... Other Weekend*coverage/. *_SPECIFIC RESPONSIBILITIES:_* The Utilization Review (UR) Registered Nurse is responsible for evaluating the medical necessity, appropriateness,… more
- Nuvance Health (Danbury, CT)
- …and operational oversight for a team of utilization review staff, denials and appeals specialists, non- clinical support staff while partnering with local case ... appeals specialists to meticulously investigate denied claims, prepare comprehensive appeals , and collaborate with clinical staff to ensure successful… more
- State of Colorado (Denver, CO)
- …Ensures equipment and supplies dispensed from department office are charged to appropriate coding string(s). The Clinical MHC III will be responsible for the ... and inclusion + Strong family and community partnerships The Clinical Mental Health Clinician III works in the 24-hour...member who operates under the supervision of a licensed nurse within Nursing Services. This position is generally responsible… more
- Molina Healthcare (Orem, UT)
- …for a RN with experience with appeals , claims review, and medical coding . JOB DESCRIPTION Job SummaryProvides support for clinical member services review ... For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is...that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members… more