Appeals Nurse

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This position requires NY RN Licensure. Daily responsibilities include researching medical history and preparing legal... documents to be submitted to court. UM/Case Management experience highly preferred as well as excellent writing capabilities. 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 • Review clinical data to determine claim payment based on company policies and • National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review • Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received • 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 reputed company • Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution • Gather and prepare case information for Administrative Law Hearings • Maintain appeals process reputed company the prescribed NCQA timeframes and appeals turnaround database • Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements. Education/Experience: NYS RN with 2+ years of clinical nursing experience. Proficient with reputed company Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred. For Fidelis Care only: NYS RN license required. Pay Range: $25.97 - $46.68 per hour reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law. Total compensation may also include additional forms of incentives. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law Apply Job! For more such jobs please click here!