UR Registered Nurse – Clinical Appeals & Denials Specialist - Remote

Cognizant is one of the world's leading professional services companies, transforming clients' business, operating, and technology models for the digital era. Our unique industry-based, consultative approach helps clients envision, build, and run more innovative and efficient businesses. Headquartered in the U.S., Cognizant (a member of the NASDAQ-100 and one of Forbes World’s Best Employers 2024) is consistently listed among the most admired companies in the world. Learn how Cognizant helps clients lead with digital at www.cognizant.com

Schedule: Monday to Friday - Eastern Time Location: Remote About the role: As a Registered Nurse you will make an impact by performing advanced level work related to clinical denial management and managing clinical denials from Providers to the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member of the Cognizant team and work collaboratively with stakeholders and other teams.

Maintain ownership and responsibility for assigned accounts. Maintain working knowledge of applicable health insurers’ internal claims, appeals, and retro-authorization as well as timely filing deadlines and processes. Review clinical denials including but not limited to referral, preauthorization, medical necessity, non-covered services, investigational/experimental and billing resulting in denials and/or delays in payment. Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and third-party guidelines. Effectively document and log claims/appeals information on relevant tracking systems Utilize critical thinking skills to interpret guidelines of internal policies for clinical determination. Medical Necessity Reviews can be based on InterQual, Milliman Clinical Guidelines (MCG), Medicare guidelines, and health insurer specific guidelines. Review retro-authorizations in accordance with health insurer requirements and follow insurer process guidelines. Identify denial patterns with clients to mitigate risk and minimize regulatory penalties. Escalate potential risks to client, client partners and/or leadership. Demonstrates critical thinking skills to interpret guidelines of internal policies for clinical determination We strive to provide flexibility wherever possible. Based on this role’s business requirements, this is a remote position open to qualified applicants in United States. Regardless of your working arrangement, we are here to support a healthy work-life balance though our various wellbeing programs. The working arrangements for this role are accurate as of the date of posting. This may change based on the project you’re engaged in, as well as business and client requirements. Rest assured; we will always be clear about role expectations.