Our client is currently seeking a NURSE APPEALS.
Responsible to investigate and process grievances and appeals requests from members and providers.
This job will have the following Responsibilities:
Conducts investigations and reviews of member and provider grievances and appeals.
Reviews prospective, concurrent or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes essential 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 appropriate written correspondence to providers, members, and regulatory entities.
Qualifications & Requirements:
Requires broad and deep knowledge of medical policy, emerging technology and analysis of emerging evidence.
Requires oral and written communication skills, problem-solving skills, PC skills, and research and analytical skills.
Requires Associate's Degree in Nursing and 2-3 years experience in a managed care healthcare setting, or any combination of education and experience, which would provide an equivalent background.
Requires current unrestricted RN license in applicable state(s).
BSN preferred.

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