Medicare Appeals Professional with Licensed Nurse

C-HIT

Columbia, MD

Responsibilities:

Reviews medical records/case file, writes a reconsideration decision letter that is clear, concise, and impartial and supports the determination made, and documents review.
Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy.
Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures.
Participates in case specific verbal discussions.
Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
Plans responses to statistical analysis challenges with assistance from statisticians.
Attends meetings and participates in workgroups at the direction of management.
Conducts quality reviews, as needed.
Serves as a subject matter expert.
Mentors and/or trains staff.
May conduct quality reviews and audits.
Participates in special projects and performs other duties as assigned.

Experience Must:

Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting
Licensed nurse with 3 or more years of experience conducting appeals
Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience
Demonstrated experience writing or making medical necessity decisions
Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred

Minimum Education Qualifications:

Associate's degree or 60 or more credit hours towards a Bachelor's degree from an accredited college or university in healthcare or related discipline Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for Associate's degree on a year per year basis.

"C-HIT is an EOE, including disability and veterans."

Apply

Vacancy posted 1 day ago

Similar jobs that could be interesting for youBased on the Medicare Appeals Professional with Licensed Nurse in Columbia, MD vacancy

Emergency Services Nurse Manager
...Step into 2026 as an Emergency Services Nurse Manager and unite meaningful patient... ...technology, career-defining growth, and an appealing Southern Maryland lifestyle in one high... ...where experienced nurses can lead with professional autonomy, sound clinical judgment, and...
Suggested
Full time
Shift work
Clinical Management Consultants
Columbia, MD
11 days ago
Nurse Practitioner - Gynecology Oncology (Part-Time 20 to 29 hours weekly)
...Nurse Practitioner Under general supervision, and in collaboration with physician colleagues, responsible for diagnosing and treating patients. Provides continuity... ...Demonstrates ability to promote professionalism through involvement in professional organizations...
Suggested
Part time
Work experience placement
University of Maryland Faculty Physicians
Columbia, MD
1 day ago
Remote Nurse Practitioner (Cardiology)
$120k - $146k
...Description Remote Cardiology Nurse Practitioner (NP) – Join a... ...looking for the perfect balance of professional autonomy and clinical impact?... ..., while coordinating closely with cardiologists and sub... ...unencumbered Nurse Practitioner license. ~3+ years of direct outpatient...
Suggested
Remote work
Flexible hours
Auxira Health, Inc.
Columbia, MD
more than 2 months ago
Clinical Medical Review Nurse
Clinical Medical Review Nurse Elite... ...to day review of professional and institutional... ...claims and provider appeals that require medical... ...Commercial, FEP and Medicare Advantage Plans.... ...and review sessions with Medical and Dental... ...RN or LPN nursing license, issued in the one...
Suggested
Temporary work
Elite Technical
Columbia, MD
12 days ago
Travel Nurse RN - OR - Operating Room - $2,349 per week
$2,349 per week
...TotalMed RN is seeking a travel nurse RN OR - Operating Room for a travel nursing job... ...hours per week (subject to confirmation) with tax-free stipend amount to be determined... ...specializes in recruiting and placing healthcare professionals in travel, PRN, and permanent positions...
Suggested
Weekly pay
Permanent employment
Zero hours contract
Relief
Local area
Immediate start
Shift work
TotalMed RN
Columbia, MD
3 days ago
Manager, Nursing (RN) - Emergency Department
$102.61k - $197k
...Manager of Appeals Complaints and Grievances Responsible for day... ...team. This role will be tasked with overseeing intake the development... ...~ Bachelor's degree in Nursing required Experience ~ Experience... ...onsite per week required Licenses and Certifications RN -...
2 days per week
Medstar Health
Columbia, MD
4 days ago
Certified Registered Nurse Anesthetist
...anesthesiologists and highly qualified Certified Registered Nurse Anesthetists (CRNAs), many with advanced training in cardiac and pediatric anesthesia.... ...matching contributions Continued education and professional reimbursement fund Liberal time off program with...
Full time
Local area
Immediate start
Relocation
Relocation package
Flexible hours
US Anesthesia Partners
Columbia, MD
2 days ago
Certified Registered Nurse Anesthetist (CRNA)
$200.75k - $285k
...looking for Certified Registered Nurse Anesthetists (CRNA) across... ...CME stipend, plus reimbursed license & medical staff fees Paid... ...Paid short-term disability with 100% salary continuation Exclusive... ...challenging and brings great professional relationships with physician...
Temporary work
For contractors
Work experience placement
Local area
MedStar Health
Columbia, MD
a month ago
Perioperative Nurse (RN), Surgery, PRN
...Orthopedic Operating Room Nurse (PRN) Platinum Medical Staffing... ..., D.C., and Virginia regions with excellence. Renowned for... ...exceptional team. If you're a driven professional eager to elevate your career,... ...re Looking For: Active RN license in Maryland, D.C., or...
Relief
Flexible hours
Shift work
Platinum Medical Staffing
Fulton, MD
5 days ago
Experienced Cardiology Physician Assistant/Nurse Practitioner
$115k - $190k
...MedStar Health is the largest health system in the region, with more than 35,000 associates, 10 hospitals, and more than 700 access... ...to advancing leadership and career opportunities for diverse professionals This position has a hiring range of: USD $115,000.00 -...
Relocation package
Shift work
Night shift
Weekend work
Credenza Health
Columbia, MD
5 days ago
Nurse, Clinical Medical Review
...Position: Nurse, Clinical Medical Review Location: Columbia, MD (DMV Local Only) Duration... ...Clinical Medical Review Nurse/Specialist with a clinical background (RN/LPN or nursing... ...experienced HEDIS abstraction/overread professional with deep NCQA/HEDIS knowledge, payer or...
Contract work
Work experience placement
Work at office
Local area
Shift work
KMM Technologies, Inc.
Columbia, MD
23 hours ago
Nurse, Clinical Medical Review
...Position: Nurse, Clinical Medical Review Location: Columbia, MD (DMV Local Only) Duration... ...Clinical Medical Review Nurse/Specialist with a clinical background (RN/LPN or nursing... ...experienced HEDIS abstraction/overread professional with deep NCQA/HEDIS knowledge, payer or...
Contract work
Work experience placement
Work at office
Local area
Shift work
KMM Technologies, Inc.
Columbia, MD
2 days ago
Clinical Medical Review Nurse
...looking for a Clinical Medical Review Nurse for their Columbia, MD/Hybrid location.... ...Clinical Medical Review Specialist (a professional with clinical experience) will report to the... ...HEDIS vendor is preferred ~ Nursing license plus bachelor's degree in Nursing, Associate...
Work at office
Shift work
ICONMA
Columbia, MD
4 days ago
Nurse Practitioner
...Nurse Practitioner The Nurse Practitioner provides clinical... ...comprehensive documentation Professionalism Seeks physician... ...Abilities Ability to work with a multidisciplinary clinical... ...certification, DEA and Maryland CDS, X license Interest in and/or...
Work at office
Chase Brexton Health Care
Columbia, MD
2 days ago
SURGICAL ASSISTANT - PRN
...passion for healthcare innovation. Grow professionally in an impactful and meaningful role, contributing... ...surgical specialties preferred. LICENSES & CERTIFICATIONS : Board certified... ...hour. Compensation will be commensurate with equity and experience for roles of...
Casual work
Relief
Local area
Weekend work
Day shift
Johns Hopkins Medicine
Columbia, MD
4 days ago
Senior Surgical Technologist
...values your skills and passion for healthcare innovation. Grow professionally in an impactful and meaningful role, contributing to cutting-... .../hour - Maximum 46.87/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility...
Part time
Work experience placement
Night shift
Weekend work
Johns Hopkins Medicine
Columbia, MD
3 days ago
Psychiatric Mental Health Nurse Practitioner (PMHNP)
...behavioral health company of mental health professionals committed to improving access to... ...patient care is delivered in accordance with applicable laws, regulations, and ethical... ...Job Requirements: Must have a PMHNP license and open to licensing in alternative states...
Work experience placement
Work from home
Day shift
Afternoon shift
BlueSky Telepsych
Columbia, MD
1 day ago
Nurse Practitioner - Care at Home - Washington D.C.
$109.5k - $164k
...Nurse Practitioner $40,000 Student Loan Repayment Or $20,000... ...Care at Home product, together with an interdisciplinary care team... ...; offering a superior professional environment and incredible opportunities... ...and unrestricted driver's license In addition to a driver's...
Minimum wage
Temporary work
Work experience placement
Local area
Relocation package
Weekend work
Reliant Medical Group
Columbia, MD
3 days ago
Matron for Surgery
$95k - $120k
...Nurse Practitioner Salary Range $95,000.00 - $120,000.00 Salary... ...outpatient vein treatment with compassion, trust, and a commitment... ...structure that supports both professional growth and personal well-... ...Requirements: Must be licensed Nurse Practitioner Minimum...
Full time
Temporary work
Local area
Shift work
Center for Vein Restoration
Columbia, MD
2 days ago
Clinical Medical Review Nurse HEDIS Retrospective Project
...Clinical Medical Review Nurse HEDIS Retrospective Project Lumen... ...experienced business and IT professionals supporting clients from... ...position is primarily remote, with occasional onsite provider visits... ...~ Active applicable clinical license is preferred/required based on...
Remote work
Lumen Solutions Group Inc.
Columbia, MD
1 day ago
Nurse Practitioner, Palliative Care PRN
$55 - $63 per hour
...Nurse Practitioner / NP, Palliative Care Location: Columbia,... ...Graduated from an approved school of professional nursing One year... ...Practitioner is preferred Licensed to practice as a Nurse Practitioner... ...plans of care for patients with chronic and terminal...
Part time
Relief
Flexible hours
AccentCare
Columbia, MD
4 days ago
Registered Nurse III - Oncology Office Practice RN - Theranostics Service
...Baltimore, MD 21287 Category: Nursing Schedule: Day Shift... ...the commitment from our entire professional staff is one of the primary reasons... ...theranostic therapies, with a primary focus on Lutathera... ...Active Maryland or Compact RN license is required BLS CPR certification...
Full time
Work experience placement
Work at office
Local area
Shift work
Day shift
Johns Hopkins Medicine
Windsor Mill, MD
1 day ago
Registered Nurse - RN - Pediatric Cardiac and Congenital OR
...Baltimore, MD 21287 Category: Nursing Schedule: Rotating Shift... ...commitment from our entire professional staff is one of the primary reasons... ...care for patients with complex congenital and acquired... ...Active Maryland or Compact RN license is required BLS CPR certification...
Full time
Work experience placement
Local area
Night shift
Rotating shift
Day shift
Johns Hopkins Medicine
Windsor Mill, MD
1 day ago
Registered Nurse (RN) NICU (FT 7P)
...and collaborates extensively with the other members of the healthcare... ...high standards of professional ethics. Position Responsibilities... ...rendered by other members of nursing department and healthcare... ...Licensure: Must have valid NJ RN License. Approved licenses must be...
Virtua, Inc.
Laurel, MD
4 days ago
Registered Nurse Lead - NICU
...hospital has grown into a comprehensive acute care medical center with 226 licensed beds. In June 1998, Howard County General Hospital joined... ...Center. Unit/role info: NICU The lead clinical nurse coordinates the total care for a group of patients throughout...
Local area
Flexible hours
Shift work
Night shift
Johns Hopkins Medicine
Columbia, MD
1 day ago
Psychiatric Mental Health Nurse Practitioner, MD License - PMHNP - Contract/1099
$120 - $140 per hour
...owned, and operated by dedicated professionals. We believe that providing... ...care for children starts with building the best possible team... ...a Psychiatric Mental Health Nurse Practitioner at Blackbird Health... ...you'll need: Active PMHNP license in Maryland A minimum of 2...
Contract work
Remote work
10 hours per week
Blackbird Health
Maryland, MD
a month ago
Registered Nurse (RN) Intensive Care Unit ICU - Relocation Offered!
$6,000 per month
...jump-start your critical care nursing career? Are you looking to... ...Nurses are supported each shift with a dedicated charge nurse.... ...dynamic and dedicated team of professional nurses, the MedStar Medical Center... ...required Active MD RN License or Active Compact State RN and...
Full time
Relocation
Relocation package
Flexible hours
Shift work
Night shift
Rotating shift
Day shift
MedStar Health
Olney, MD
12 days ago
Aesthetics Injectables Nurse Practitioner or Physician Assistant
...Aesthetics Injectables Nurse Practitioner or Physician Assistant - Columbia, Maryland Job#... ...care plans, and collaborate closely with advanced aesthetic providers to ensure safe... ...Active and unrestricted Maryland NP or PA license This part of the county offers abundant...
Addison Kenway.
Columbia, MD
3 days ago
Aesthetics Injectables Nurse Practitioner or Physician Assistant Injector
...Aesthetics Injectables Nurse Practitioner or Physician Assistant Injector - Columbia, Maryland A thriving medical aesthetics practice... ...Active Nurse Practitioner or Physician Assistant license in Maryland Residents enjoy access to parks, trails, golf courses...
ADDISON KENWAY & ASSOCIATES LLC
Columbia, MD
23 hours ago
SURGICAL TECH I NON-CERT- Labor & Delivery
...values your skills and passion for healthcare innovation. Grow professionally in an impactful and meaningful role, contributing to cutting-... .../hour - Maximum 31.21/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility...
Local area
Weekend work
Day shift
Johns Hopkins Medicine
Columbia, MD
4 days ago

Do you want to receive more vacancies?

Subscribe and receive similar vacancies to Medicare Appeals Professional with Licensed Nurse. Be the first to apply!