Medicare PAR Provider Appeals Nurse Consultant

We're building a world of health around every individual , shaping a more connected, convenient, and compassionate health experience.

This is a full-time remote position working from home in Connecticut, supporting PAR Provider Post Service payment disputes and appeals.

Primary Responsibilities:

• Request and research submitted provider clinical information to support case review and determination processes.
• Review documentation to identify relevant clinical details and apply CMS guidelines, regulatory requirements, and applicable supplemental policies.
• Prepare a comprehensive nurse summary for medical director evaluation or finalize appeal determinations in accordance with pre-approved workflows.
• Navigate and manage multiple computer systems and applications to ensure timely, accurate, and compliant processing of cases.
• Work independently with a high degree of self-motivation while contributing to teamwork and collaboration in a virtual environment.

Clinical Appeals Team:

• UM Outpatient: Reviews denied procedures, imaging, and medications that require prior authorization.
• UM Inpatient: Reviews denied inpatient stays, including hospital, hospital readmissions, behavioral health, skilled nursing, acute rehabilitation, and long-term acute care stays.
• DRG: Reviews and evaluates down-coded claims to determine if the assigned Diagnosis Related Group (DRG) is supported.
• Coding: Reviews clinical documentation and coding to evaluate the appropriateness of denied claims.
• MPO: Conducts clinical reviews for claim denials, determining whether cases should be overturned or prepared for MD review.

Required Qualifications:

• 3-5 years of experience as a Registered Nurse
• Minimum 3+ years of clinical/hospital nursing experience

Preferred Qualifications:

• 1+ years in Medicare Utilization Management, case review, or prior authorization
• Utilization Management, Managed Care, or Appeals experience preferred
• Coding experience preferred
• Pre-Authorization experience preferred

Education and Licensure Requirements:

• Registered Nurse - associate's degree or Diploma RN required, BSN preferred
• Active RN State License Required

Anticipated Weekly Hours: 40

Time Type: Full-time

Pay Range: $66,575.00 - $142,576.00

Benefits: Eligible for a comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources.