Nurse Auditor (Clinical Appeals)

Elevate Patient Financial Solutions has an exciting career opportunity available as a Nurse Auditor. This position will be a remote based role. The Full-Time schedule for this role will be Monday-Friday 8:00am-5:00pm. The Nurse Auditor is responsible for performing specialized administrative duties within the billing and reimbursement services department. The Nurse Auditor is responsible for running regular audits, reviewing medical records to justify level of care, and preparing appeal letters when gathered evidence does not support denial of services. Essential Duties and Responsibilities

• Authorization Denials
• Prepare a clinical reconsideration/appeal letter to submit to the payer based on the evidence in the patient’s medical records to justify either an acute level of care or skilled level of care (based on results from either MCG or InterQual review).
• Medical Necessity Denial Reviews
• Prepare a clinical reconsideration/appeal letter to submit to the payer based on the evidence in the patients’ medical records that supports the necessity for denied services.
• Other Denial Reviews for Appeal:
• DRG Downgrades
• MAC & RAC Audits
• Payer Utilization Review Audits
• Experimental Procedures
• Charge Audits
• Other duties as assigned.

Qualifications and Requirements To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or abilities.

• Utilization Review
• Case Management
• Preparing and submitting Authorizations
• Use of InterQual and/or MCG
• Inpatient Clinical Experience
• Registered Nurse; or
• Licensed Vocational Nurse
• Remote and Hybrid positions require a home internet connection that meets the company’s upload and download speed criteria.

Benefits: ElevatePFS believes in making a positive impact not only within our industry but also with our employees –the organization’s greatest asset! We take pride in offering comprehensive benefits in a vast array of plans that contribute to the present and future well-being of our employees and their families.

• Medical, Dental & Vision Insurance
• 401K (100% match for the first 3% & 50% match for the next 2%)
• 15 days of PTO
• 7 paid Holidays
• 2 Floating holidays
• 1 Elevate Day (floating holiday)
• Pet Insurance
• Employee referral bonus program
• Teamwork: We believe in teamwork and having fun together
• Career Growth: Gain great experience to promote to higher roles

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, location, specialty and training. This pay scale is not a promise of a particular wage. The job description does not constitute an employment agreement between the employer and Employee and is subject to change by the employer as the needs of the employer and requirements of the job change. ElevatePFS is an Equal Opportunity Employer Apply tot his job Apply To this Job