Federal Hearings And Appeals·Wilkes-Barre, Pennsylvania
Perform timely review and determination of medical claims, including prior authorizations and appeals, by analyzing medical records. Formulate narrative decisions based on federal regulations, health plan policies, and NCD/LCD guidelines.
Work experience requirements
Must possess a current, unrestricted State license as a Registered Nurse (RN),as required by contract(s).
1+ years clinical experience required; coding, utilization, and/or medical chart review preferred.
Professional Coding Certification preferred.
Detailed knowledge of Medicare regulations and guidelines, polices, and payor reimbursements preferred.
Knowledge of CPT, HCPCS, ICD-10 codes and coding guidelines.
Ability to identify Medicare billing and payment irregularities.
Must be able to support review findings by utilizing exceptional analytical, written and oral communication skills.
Ethical, self-motivated and results oriented team player.
Strong analytical, verbal and written communication skills.
Outstanding people skills and ability to effectively review findings /results with management.
Must be proficient with PC and related software programs.
Excellent organizational skills.
Must be a team player.
Limited travel may be required.
Remote but need to be local to 18702
RN required
Requires a current, unrestricted Registered Nurse (RN) license and at least one year of clinical experience. Proficiency in Medicare regulations and coding guidelines (CPT, HCPCS, ICD-10) is highly preferred.
Market context
In Pennsylvania, administration roles tied to clinical research often draw steady demand from hospitals, universities, and research sites that need coordinators who can keep studies organized and compliant. These roles are competitive because employers look for candidates with direct coordinator experience, strong Microsoft Office skills, and practical clinical abilities such as phlebotomy or a willingness to train quickly. Review the AI-summarized requirements and benefits here to save time, then confirm your experience matches the study setting and be ready to discuss how you handle documentation and participant coordination.
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