About the Role
This position involves reviewing patient cases to support coverage determinations, primarily focusing on appeals related to medical necessity and insurance eligibility. The nurse consultant collaborates with healthcare teams to ensure decisions align with clinical guidelines and regulatory standards.
Responsibilities
- Evaluate clinical documentation to determine medical necessity for patient services
- Review appeals for insurance coverage based on established clinical criteria
- Collaborate with healthcare providers to gather additional clinical information
- Ensure compliance with federal and state healthcare regulations
- Document findings and decisions in patient records accurately
- Communicate coverage determinations to patients and providers
- Participate in quality improvement initiatives related to appeal processes
- Interpret clinical data to support coverage decisions
- Respond to time-sensitive appeal requests within defined service levels
- Maintain up-to-date knowledge of clinical guidelines and policy changes
- Support consistency in decision-making across similar clinical cases
- Escalate complex cases to senior clinical staff when necessary
- Contribute to process improvements in appeals management systems
- Ensure patient confidentiality in all communications and documentation
- Work cross-functionally with medical, legal, and operational teams
- Assist in training new team members on appeal procedures
- Monitor trends in appeal outcomes to identify areas for improvement
- Apply critical thinking to assess clinical scenarios objectively
- Maintain accurate records of all appeal activities
- Adhere to internal audit and compliance requirements
Compensation
Competitive salary and comprehensive benefits package including health, dental, and retirement plans.
Work Arrangement
Remote position with flexible scheduling options within defined business hours.
Team
Part of a national clinical team focused on coverage integrity and patient-centered decision-making.
Why This Role Matters
This role ensures patients receive fair and timely decisions on care coverage, balancing clinical integrity with regulatory compliance. Your work directly impacts access to essential health services.
What We Offer
- Comprehensive medical, dental, and vision coverage
- 401(k) with company match
- Paid time off and holidays
- Professional development opportunities
- Employee assistance and wellness programs
Not available for this position.
