Grievance and Appeals BH Nurse

3 weeks ago


Indianapolis, United States Professional Management Enterprises Full time
Job DescriptionJob DescriptionDescription:

Position Name: Behavioral Health Appeals Nurse

Location: Must Reside in Indiana, designated remote work position

Hours: Tuesday - Saturday (Saturday's are half days)

4 (9HR shifts) 7am-5:00pm

8am-6:00pm

9am-7:00pm


Pay $85,000k health, dental, and vision offered. 401k available. 80 hours of PTO and 11 paid holidays


Job Description

Responsible for investigating and processing the most complex grievances and appeals requests from members and providers.

Primary duties may include, but are not limited to:

  • Conducts investigations and reviews of member and provider medical necessity appeals.
  • Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
  • Extrapolates and summarizes medical information for medical director, consultants and other external review.
  • Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
  • Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
  • Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
  • Generates written correspondence to providers, members, and regulatory entities.
  • Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

Requirements:Requirements
  • Requires 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.· Behavioral Health experience
  • Current active unrestricted RN license to practice as a health professional within the scope of licensure in IN·
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • MCG (Milliman Care Guidelines) and CMCN (Certified Managed Care Nurse) certification strongly preferred
  • AS required/BS in Nursing preferred.


  • Indianapolis, United States aFit Staffing Inc. Full time

    Job DescriptionJob DescriptionMore about aFit:You want to work where you know you are a perfect fit. At aFit, a woman owned (WBE) company based in Indianapolis, we are devoted to being collaborative, honorable, and accountable. Our company provides project-based staffing for government and commercial organizations. To our prospective clients, aFit offers a...

  • Investigator I

    15 hours ago


    Indianapolis, United States Elevance Health Full time

    JR111671 Investigator lLocation : This position will work a hybrid model (remote and office). T he ideal candidate will reside WITHIN 50 miles of one of our PulsePoint locations. The associate will work fully virtual and come onsite for trainings, meetings, or as otherwise required by the manager.The Investigator l is responsible for investigating assigned...


  • Indianapolis, United States Business Health Solutions Professional Corporation Full time

    Job DescriptionJob DescriptionSalary: Join Business Health Solutions and Make a Difference in Occupational Health!At Business Health Solutions (BHS), we are committed to delivering tailored services that cater to the unique needs and objectives of our host organizations. Our team of occupational health and safety professionals is dedicated to staffing,...

  • Registered Nurse

    2 weeks ago


    Indianapolis, United States Nurses and More Full time

    Registered Nurses for Long Term Care Facilities!! Nurses and More, Inc. in Indianapolis, IN is currently looking for RN's with at least 1 full year of long term care experience within the last 3 years to help cover openings in local facilities. Nurses and More, Inc. is a Medicare/Medicaid Home Health and Staffing Agency who has been taking care of...

  • Registered Nurse

    Found in: Appcast US C2 - 2 weeks ago


    Indianapolis, United States Nurses and More Full time

    Registered Nurses for Long Term Care Facilities!! Nurses and More, Inc. in Indianapolis, IN is currently looking for RN's with at least 1 full year of long term care experience within the last 3 years to help cover openings in local facilities. Nurses and More, Inc. is a Medicare/Medicaid Home Health and Staffing Agency who has been taking care of...

  • Registered Nurse-Employee Health Services

    Found in: beBee jobs US - 9 hours ago


    Indianapolis, Indiana, United States Eli Lilly and Company Full time

    At Lilly, we unite caring with discovery to make life better for people around the world. We are a global healthcare leader headquartered in Indianapolis, Indiana. Our employees around the world work to discover and bring life-changing medicines to those who need them, improve the understanding and management of disease, and give back to our communities...


  • Indianapolis, United States The Curare Group Full time

    Seeking a Board Certified/Eligible Pulmonary Critical Care physician to join an existing practice in Indianapolis, Indiana. This is one of the area's largest multi-specialty medical groups, including more than 600 primary care and specialty physicians, as well as nurse practitioners and physician assistants in more than 100 locations across central Indiana....


  • Indianapolis, United States Business Health Solutions Professional Corporation Full time

    Job DescriptionJob DescriptionSalary: $95K - $125K AnnuallyClinical Operations Manager - Remote/TravelBusiness Health Solutions PC - Nationwide*Prefer professional to be based in Memphis, TN or Houston, TX area*  What we offer our Team!Competitive pay and performance incentivesMedical, Dental, Vision Coverages with HSA or FSAShort-Term, Long-Term...


  • Indianapolis, United States Nurses and More Full time

    Qualified Medication Aides (QMA) for Long Term Care Facilities!! Nurses and More, Inc. in Indianapolis, IN is currently looking for QMA's with at least 1 full year of long term care experience within the last 3 years to help cover openings in local facilities. Nurses and More, Inc. is a Medicare/Medicaid Home Health Care and Staffing Agency who has...


  • Indianapolis, United States Nurses and More Full time

    Qualified Medication Aides (QMA) for Long Term Care Facilities!! Nurses and More, Inc. in Indianapolis, IN is currently looking for QMA's with at least 1 full year of long term care experience within the last 3 years to help cover openings in local facilities. Nurses and More, Inc. is a Medicare/Medicaid Home Health Care and Staffing Agency who has...

  • Qualified Medication Aide

    Found in: Appcast US C2 - 3 weeks ago


    Indianapolis, United States Nurses and More Full time

    Qualified Medication Aides (QMA) for Long Term Care Facilities!! Nurses and More, Inc. in Indianapolis, IN is currently looking for QMA's with at least 1 full year of long term care experience within the last 3 years to help cover openings in local facilities. Nurses and More, Inc. is a Medicare/Medicaid Home Health Care and Staffing Agency who has...


  • Indianapolis, United States Community Health Network Full time

    Job Location Exceptional care, simply delivered, is what sets Community Health Network apart and what makes us a leading not-for-profit, multi-specialty healthcare destination in central Indiana. This provider will join one of the nation's most integrated healthcare systems, with over 1,000 providers in Indianapolis, IN. With an appealing blend of big-city...


  • Indianapolis, United States Nurses and More Full time

    SEEKING ALLIED HEALTHCARE PROFESSIONALS!! Occupational Therapist (OT) Our home health care agency is growing fast! We need strong, professional, and compassionate healthcare providers on board to help us meet the needs of our patients. Nurses and More, Inc. is a Medicare/Medicaid Certified Home Health Care and Staffing agency in Indianapolis,...

  • Occupational Therapist

    Found in: Appcast US C2 - 2 weeks ago


    Indianapolis, United States Nurses and More Full time

    SEEKING ALLIED HEALTHCARE PROFESSIONALS!! Occupational Therapist (OT) Our home health care agency is growing fast! We need strong, professional, and compassionate healthcare providers on board to help us meet the needs of our patients. Nurses and More, Inc. is a Medicare/Medicaid Certified Home Health Care and Staffing agency in Indianapolis,...

  • Travel nurse

    Found in: Jooble US O C2 - 3 days ago


    Indianapolis, IN, United States Health Carousel Travel Nursing and Allied Health Full time

    Health Carousel Nursing and Allied Health is seeking a qualified Dialysis Travel RN for the following assignment: Estimated Start Date: 5/13/2024 Location: Indianapolis, IN Shift: Days Hours Per Week: 40 Assignment Length: 13 weeks


  • Indianapolis, United States Indiana University Health Full time

    Job Description The Annual Fund Analyst grows IU Health Foundation's impact by increasing the number of donors and the volume of gifts received. Engaging grateful patients, community members, volunteers and IU Health employees, the analyst ideates and executes direct response programs that inspire. To attract new donors and retain current donors, the analyst...

  • QMA Nights

    2 weeks ago


    Indianapolis, United States Rittenhouse Village at Northside Full time

    Job DescriptionJob DescriptionOur community is looking for a Care/Medication Technician to join our team.The Care Giver/Med Tech role includes providing hands on care, physical and emotional support to each resident while maintaining a safe and comfortable home like environment.Responsibilities:Care Giver:Responsible for a designated group of residents...

  • Behavioral Health Medical Director-Psychiatrist or HSPP

    Found in: Resume Library US A2 - 2 weeks ago


    Indianapolis, Indiana, United States CNSI Full time

    Job Description Acentra seeks a Behavioral Health Medical Director Psychiatrist or HSPP (Indiana license) to join our growing team for a Hybrid role in Indianapolis, Indiana. Job Summary: Evaluate, redirect, and/or respond to inquiries from physicians, providers, and customers. Consult with general and/or specialty practitioners regularly and as...

  • Pediatric Hematologist

    Found in: Lensa US P 2 C2 - 2 weeks ago


    Indianapolis, United States Indiana Hemophilia and Thrombosis Center Full time

    What You Will Do As a Hematologist, you will be responsible for the diagnosis and care of patients with hematologic disorders and follow-up of patients seen in the hospital. Additional responsibilities will include participation in on-call rotation for inpatient and program coverage. The Opportunity Diagnosis and care of patients with hematologic disorders...

  • Pharmacy Liaison

    2 days ago


    Indianapolis, United States AndHealth Full time

    Patient Engagement Specialist Full Time Indianapolis, IN AndHealth is a healthcare technology company created to help people reverse chronic disease. We are driven by the goal of making world-class specialty care accessible and affordable to all. We partner with health systems, community health centers, plans, and employers to remove barriers to care to...