Top 31 Utilization management reviewer Jobs in Gastonia, Nc

Utilization Review RN Appeals Specialist
CaroMont Health —Gastonia, NC
- Full-time
- Nursing
- RN License
- Hospital
Behavioral Health UM Reviewer (Licensed)-Adult Team-Remote-NC
Partners Health Management —Gastonia, NC
- $60,653.49 - $75,816.87 a year
- 8 hour shift
- Remote
- LMFT
- Nursing
- Microsoft Excel
- Paid holidays
- Disability insurance
Employee Benefit Analyst IV
USI Holdings Corporation —Charlotte, NC
- Remote
- Computer literacy
- Mid-level
- High school diploma or GED
- Wellness program
- Health savings account
Department Manager | Environmental Due Diligence and Remediation Services - Charlotte
BUNNELL LAMMONS ENGINEERING —Charlotte, NC
- Full-time
- 8 years
- Travel
- Senior level
- Paid holidays
- Disability insurance
Quick Apply
Department Manager | CMT Services - Charlotte
BUNNELL LAMMONS ENGINEERING —Charlotte, NC
- Full-time
- 8 years
- Travel
- Senior level
- Paid holidays
- Disability insurance
Quick Apply
Prior Authorization Systems Pharmacist
Judi Health —Charlotte, NC
- $128,000 - $150,000 a year
- Full-time
- Microsoft Word
- System design
- 3 years
- Wellness program
- Health savings account
Quick Apply
Department Manager | Geotechnical Services - Charlotte
BUNNELL LAMMONS ENGINEERING —Charlotte, NC
- Full-time
- 8 years
- Analysis skills
- Travel
- Paid holidays
- Disability insurance
Quick Apply
Practice Area Leader - Structural Practice Group
Terracon —Charlotte, NC
- Engineering
- Office
- 8 years
- Paid holidays
- Health insurance
Staff Associate | Geostructures
BUNNELL LAMMONS ENGINEERING —Charlotte, NC
- Full-time
- Travel
- US work authorization
- 2 years
- Paid holidays
- Disability insurance
Quick Apply
Utilization Management Reviewer
Amerihealth Caritas —United States
- Full-time
- Hybrid work
- Nursing
- Microsoft Outlook
- RN License
- Paid holidays
- Health insurance

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Utilization Review RN Appeals Specialist

CaroMont Health -
Gastonia, NC

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Job Details

Full-time

Qualifications

Appeals
Medicare
RN License
Writing skills
CMS regulatory compliance
Case appeal in utilization management
Bachelor's degree
Medicare regulations
Centers for Medicare and Medicaid Services (CMS)
Health record chart audits
Resource utilization in healthcare
Medicaid regulations
Regulatory compliance analysis
Insurance claims appeal handling

Full Job Description

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: Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is warranted. Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted. Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments. Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Discuss documentation-related, level of care decisions, and clinical issues with physicians and other appropriate staff. Ensure compliance with HIPAA regulations, to include confidentiality, as required. Other duties as assigned. Works closely with the Utilization Review Specialists to ensure that concurrent medical necessity is achieved. Additionally, works with outside surgical offices when called upon, to provide Medicare Inpatient Only List knowledge to ensure that surgical procedures are correctly called in and billed appropriately.

Qualifications: Bachelor's degree from an accredited college with a strong clinical background, MSN preferred. Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required. Knowledge in areas such as InterQual Level of Care Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred. Must have excellent oral communication and organizational skills. Must have excellent writing skills. Previous experience with clinical resource utilization analysis, auditing, appeal writing, and chart review. Knowledge of state and federal regulations in regard to Medicare and Quality Management activities is a must. . Certification is required within one year of hire.

EOE AA M/F/Vet/Disability

Location: CaroMont Health · Utilization Review
Schedule: Full Time, 8:30am-5:00pm

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Refine Your Search

utilization management reviewer jobs in gastonia, nc

Utilization Review RN Appeals Specialist

Behavioral Health UM Reviewer (Licensed)-Adult Team-Remote-NC

Employee Benefit Analyst IV

Department Manager | Environmental Due Diligence and Remediation Services - Charlotte

Department Manager | CMT Services - Charlotte

Prior Authorization Systems Pharmacist

Department Manager | Geotechnical Services - Charlotte

Practice Area Leader - Structural Practice Group

Staff Associate | Geostructures

Utilization Management Reviewer

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