Job Description

Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and diagnosis-related groups (DRG) reassignments

Responsibilities

• Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients
• Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments
• Participate in Administrative Law Judge (ALJ) Hearings, presenting oral arguments to support the reversal of Medicare denials
• Analyze denial patterns and contribute insights to help reduce future denials
• Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes
• Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process

Qualifications

Required

• Bachelor's of Science in Nursing (BSN) or equivalent degree
• Current and unrestricted RN license
• At least 5 years of clinical experience in acute care settings
• At least 3 years of experience in case management, utilization review, or clinical appeals
• Exceptional written and verbal communication skills
• Proficiency with MS Office suite, particularly Word and Excel
• Strong analytical and problem-solving skills with attention to detail

Preferred

• Experience with payer-side case management or medical director-level review

Expectations

• Comfortable with remote work arrangements and virtual collaboration tools
• May require occasional travel for conferences, client meetings, or in-person hearings
• Physical demands include extended periods of sitting, computer use, and telephone communication

Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

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All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.

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