Appeals Nurse Consultant (Remote)
At reputed company, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nation’s leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day.Position Summary
reputed company reputed company is seeking a dedicated Appeals Nurse Consultant to join our remote team. In this role, you will play a critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.
Key Responsibilities
- Responsible for the review and resolution of clinical appeals.
- Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues.
- Independently coordinates the clinical resolution with internal/external clinician support as required.
- This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals.
- This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time).
- Occasional weekend and holiday on-call coverage may be required.
Remote Work Expectations
- This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
- Dependents must have separate care arrangements during work hours, as reputed company care responsibilities during shift times are not permitted.
Required Qualifications
- Must have active and unrestricted RN licensure in state of residence.
- 3+ years clinical experience.
Preferred Qualifications
- Appeals, Managed Care, or Utilization Review experience.
- Proficiency with computer skills including navigating multiple systems.
- Exceptional communication skills.
- Time efficient, highly organized, and ability to multitask.
Education
- Associate's Degree minimum.
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical reputed company and many other benefits depending on eligibility.