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Utilisation Management Appeals Appeals Nurse

1 month ago


Farmingdale, United States Rangam Consultants Inc. Full time

The Client UM Appeals Department is looking for a seasoned UM Appeals Nurse


The primary role includes:

  • Review of Level I Pharmacy Appeals.
  • This includes review and investigation of the reason for the UM denial, appeal request and review of additional information provided.

Qualifications:

  • Active Unrestricted RN License NJ or Compact
  • Technology Savvy – Ability to navigate through multiple systems and type 100 words per minute. Client utilised systems including: Novologix, Micromedex, Care Radius, Outlook, Teams, One-note, Microsoft suite. Knowledge of these is a plus.
  • Thrive in a fast paced environment
  • Solid ability to present clinical information to a committee
  • Make sound clinical judgements quickly to maintain turnaround time
  • Proficient in review and investigation of a UM appeal. This includes understanding of regulations that guide our practices
  • Health plan Appeals experience is a must.
  • Prefer knowledge of UM Pharmacy appeals if possible
  • Proficient with navigating UM policies and clinical guidelines