Clinical Review RN - 249062

Medix provides workforce solutions to clients and creates opportunity for talent in the Healthcare, Life Sciences, Engineering and Technology fields. Through our core purpose of positively impacting lives, we have earned our reputation as an industry leader by providing unsurpassed customer service and top quality professionals to our clients.

Job Title: Clinical Review RN (Independent Dispute Resolution/Appeals) Experience: Open to various clinical backgrounds/experience. Appeals experience not required. Must have 2+ years of clinical experience post clinicals. Must has strong computer skills, critical thinking and problem solving skills. ***Must have BSN and New York State RN license*** Location: Remote for the first 3-4 months and then will be asked to work full time onsite in Jericho or Albany, NY once there is enough office space ***free shuttle from the Jericho LIRR station to the office + parking onsite Hours of Operation: M-F between operating hours of 7a-5:30p *flexible start between 7am-9am (40hrs/wk) Start date: ASAP Pay: $50-53/hr DOE Volume: Will do appeals work under the IDR team handling on average 10 cases a day. These will be a mix between simple and complex cases. They will be reviewing documentation, codes, and more for out of Network bills and cost and making determinations on how to move forward based on the evidence. This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical level review, Prior Authorization, and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements, complete electronic worksheets and preparing final determinations. Act as a resource for the administrative and clinical staff in training, problem solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles. Training and mentoring new RNs as the project expands. Claims assessment and adjudication. Participate in collaborative training. Other activities as may be deemed necessary.