Clinical Appeals & Medical Audit RN Specialist

About the job

Connext Global Solutions is a dedicated team of business process outsourcing experts and innovators, with experience in supporting world-class companies in Title and Escrow, Healthcare, Produce Distribution, Retail and Fashion, Design Consulting, and Finance.

We are currently looking for a Clinical Appeals & Medical Audit RN Specialist who will be working with Connext's client in the US.

What’s in it for you

• ?Competitive compensatio
• nPerfect Attendance Bonu
• sLife insuranc
• eHMO Insuranc
• eGreat company cultur
• eAnnual Merit Increas
• eWork Onsite (Bajada, Davao

)
What is the jo

b?As a Medical Audit Nurse, you will be responsible for conducting comprehensive audits of medical records to support appeals, defense audits, and evaluations of disallowed charges. Your clinical expertise will be crucial in determining medical necessity, drafting appeal letters, and ensuring compliance with regulatory and payer guideline

s.
Responsibiliti

• es:Perform audits of medical records for defense audits, patient inquiries, disallowed charges, and biller-requested revie
• ws.Analyze documentation using InterQual, MCG, Medicare/Medicaid, and commercial payer criter
• ia.Support appeals for avoidable length of stay, RAC audits, CERT, ZPIC, and SMRC cas
• es.Compose clear, clinically sound appeal letters addressing medical and contractual issu
• es.Request additional documentation from healthcare providers and review supporting literatu
• re.Enter audit findings into client systems with high accuracy and deta
• il.Work across multiple systems including EMRs, billing, and quality platfor
• ms.Ensure compliance with HIPAA, FDCPA, FCRA, and internal polici
• es.Handle sensitive patient information confidentially and secure
• ly.Maintain up-to-date knowledge of healthcare regulations, payer policies, and audit best practic

es.
Qualificati

• ons:Bachelor’s degree in nur
• singActive Registered Nurse (RN) lic
• ense3 to 5 years of clinical experience or relevant experience in auditing, appeals, utilization review, or denials manage
• mentExperience in medical records review or claims proces
• singStrong knowledge of Medicare/Medicaid regulat
• ionsProficient in electronic medical records and Microsoft Of
• ficeExcellent critical thinking, clinical judgment, and attention to de
• tailAbility to interpret complex clinical documentation and payer guidel
• inesStrong written communication and customer service sk

ills
Prefe

• rred:Certifications in case management, utilization review, or medical c
• odingFamiliarity with InterQual and MCG cri