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Nurse Appeals
2 months ago
Nurse Appeals – Licensed RN Nurse
Location: This position will work in a hybrid model (remote and office). Ideal candidates will live in Virginia, Georgia, Florida, Indiana, or Ohio within 50 miles of one of our PulsePoint locations.
Shift: Monday to Friday from 8:00 am - 5:00 pm ET or Tuesday to Saturday from 8:00 am – 5:00 pm ET (will work weekends and holidays as needed).
The Nurse Appeals position is responsible for investigating and processing medical necessity appeals requests from members and providers.
How you will make an impact
Primary duties may include, but are not limited to:
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Conducts investigations and reviews of member and provider medical necessity appeals.
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Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
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Extrapolates and summarizes medical information for medical director, consultants, and other external review.
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Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
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Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
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Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
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Generates written correspondence to providers, members, and regulatory entities.
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Utilizes 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.
Minimum Requirements:
- Requires minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
Preferred Skills, Capabilities, and Experiences :
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AS or BS in Nursing preferred.
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Utilization management experience preferred.
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Demonstrate proficiency in utilizing Microsoft Office functionalities.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
