Registered Nurse (Claims & Appeals Review)
Compunnel Inc.
Overview
Job Title: Registered Nurse – Claims & Appeals Review
Location: Remote (Anywhere in Florida)
Duration: 06 Months/Can be Extended
Working hours: Day Shift
Job Type: Subcon
Pay Rate: Negotiable
Position Description
The Quality Analyst is responsible for ensuring the accuracy, compliance, and timeliness of appeal reviews through both manual and automated reporting mechanisms. This role supports continuous improvement in clinical operations by identifying quality gaps, performing root cause analysis, and recommending corrective actions.
Key Responsibilities
- Review appeal cases and supporting documentation to ensure completeness and compliance with InterQual and contractual guidelines.
- Conduct manual audits and reporting to assess quality of appeal decisions and documentation.
- Analyze operational data and performance metrics to identify trends, errors, and improvement opportunities.
- Collaborate with clinicians and MD reviewers to validate decisions and escalate complex cases.
- Maintain dashboards and SLA tracking for appeals turnaround time, audit coverage, and accuracy.
- Support calibration sessions and feedback loops with transaction monitors and team leads.
- Document findings and prepare reports for internal and client-facing reviews.
- Ensure compliance with NCQA, CMS, and state regulations.
Qualifications
Education/Experience
- Bachelor’s degree in healthcare, life sciences, or related field preferred
- 2+ years of experience in appeals, grievance, or quality assurance in a healthcare setting
- Experience with audit tools, EMR systems, and reporting platforms
Licensure/Certification
- Valid RN, LPN, or LVN license in applicable state (Florida)
Skills
- Strong analytical, leadership and documentation skills
- Proficiency in Excel and data visualization tools
- Familiarity with InterQual criteria and CMS guidelines
- Ability to work independently and manage multiple priorities
Additional Details
- Seniority level: Mid-Senior level
- Employment type: Contract
- Job function: Health Care Provider
- Industries: Hospitals and Health Care and Public Health
Vacancy posted 10 hours ago
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