Appeals Nurse

Position Title: Appeals Nurse

Work Location: Remote

Assignment Duration: 08 Months

Work Schedule: M-F

Work Arrangement: Remote

Position Summary: Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

Background & Context:

Education/Experience: LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.

License/Certification: RN or LPN license.

For our organization only: NYS RN license required.

Key Responsibilities:

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  Review clinical data to determine claim payment based on company policies and

  
  
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  National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review

  
  
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  Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received

  
  
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  Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions

  
  
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  Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution

  
  
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  Gather and prepare case information for Administrative Law Hearings

  
  
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  Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database

  
  
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  Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements.