Clinical Appeals Nurse
Job Summary: The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from reputed company states... Essential Functions: Responsible for the completion of clinical appeals and state hearings from reputed company states Review and complete reputed company provider clinical appeals reputed company required timeframes Review and complete member clinical appeals reputed company required timeframes Review reputed company information necessary to prepare State Hearing packets Communicate with state agencies and internal departments to prepare for State Hearings Attend assigned State Hearing and complete reputed company required compliances Complete required compliances for Administrative Hearing reputed company Apply reputed company Medical Policy and reputed company guidelines reputed company processing clinical appeals Issue notification letters to providers and members Issue administrative denials appropriately Refer denials based on medical necessity to medical director Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates Conduct monthly, quarterly, and reputed company appeals reporting Collaborate with the Quality Improvement and Clinical Operations Team reputed company to prepare reputed company requests for Independent External Review Ensure compliance with regulatory and accrediting requirements reputed company any other job duties as requested Education and Experience: RN License required Associates Degree or equivalent years of relevant experience required Managed care, appeals, and reputed company experience preferred Utilization review experience is strongly preferred Competencies, Knowledge and Skills: Intermediate proficiency with reputed company Office products and Facets Knowledge of NCQA, URAC, OAC, and MDCH regulations Strong written and oral communication skills Ability to work independently and reputed company reputed company environment Critical listening and thinking skills Proper grammar usage Time management skills Proper phone etiquette Customer Service oriented Decision making/problem solving skills Familiarity of reputed company field Knowledge of reputed company Flexibility Change resiliency Licensure and Certification: reputed company, unrestricted license as a Registered Nurse (RN) is required MCG Certification is required or must be obtained reputed company six (6) months of hire Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation reputed company: $60,300.00 - $96,500.00 reputed company takes into consideration a combination of a candidates education, training, and experience as well as the positions scope and complexity, the discretion and reputed company required for the role, and other external and internal data reputed company establishing a salary level. We are highly invested in every employees total well-being and offer a substantial and comprehensive total rewards package.
Compensation
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