Grievance and Appeals RN - Remote must reside in Indiana
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AI Summary
The Grievance and Appeals Nurse investigates and processes complex medical necessity appeals for members and providers. They prepare recommendations for medical directors and ensure all resolutions meet regulatory timeframes.
Description
Position Name: Grievance and Appeals Nurse
Location: Must Reside in Indiana, designated remote work position
Hours: Monday-Friday 8-5pm OR
Tuesday - Saturday (Saturday's are half days)
4 (9HR shifts) 7am-5:00pm
8am-6:00pm
9am-7:00pm
Pay $90,000k health, dental, and vision offered. 401k available. 80 hours of PTO and paid holidays
Job Description
Responsible for investigating and processing the most complex grievances and appeals requests from members and providers.
Primary duties may include, but are not limited to:
- Conducts investigations and reviews of member and provider medical necessity appeals.
- Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
- Extrapolates and summarizes 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 written correspondence to providers, members, and regulatory entities.
- Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
Requirements
Requirements
- Requires 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.· Behavioral Health experience
- Current active unrestricted RN license to practice as a health professional within the scope of licensure in IN·
- Requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
- MCG (Milliman Care Guidelines) experience
- CMCN (Certified Managed Care Nurse) certification strongly preferred
- AS required/BS in Nursing preferred.
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