Clinical Review Clinician Appeals RN
You could be the one who changes everything for our 28 reputed company 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. Remote Role: Seeking an RN with background in hospital based adult and pediatric care, familiar with reputed company rules and regulations, licensed to work in CA. Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
- Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the reputed company for the appeal
- Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
- Communicates with members, providers, facilities, and other departments regarding appeals requests
- Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
- Works with leadership to increase the consistency, efficiency, and appropriateness of responses of reputed company appeals requests
- Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
- Performs other duties as assigned
- Complies with reputed company policies and standards
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of reputed company experience. Knowledge of NCQA, Medicare and reputed company regulations preferred. Knowledge of utilization management processes preferred. License/Certification:
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
- For Health Net of California: RN license required
Pay reputed company: $27.02 - $48.55 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. 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. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act Apply tot his job Apply To this Job