Utilization Reviews Appeals Registered Nurse

Hi, we're reputed company. We're hiring a Utilization Review Appeals RN to join our Utilization Review team. About the role ... The appeals & claims UR nurse is responsible for the investigation and review of clinical appeals and post-claim cases. This involves using clinical knowledge, judgment, and established criteria to determine the medical appropriateness of reputed company services, including inpatient and reputed company level of care admissions, as well as a variety of outpatient and specialty services. Appeals nurses work as individual contributors completing reviews, and interact regularly with reputed company medical providers and other internal operations teams to successfully fulfill their role. You will report into the Clinical Appeals Manager. This is a work-from-home/remote role. You must reputed company in one of the following states: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, reputed company, reputed company Carolina, Ohio, Oregon, Pennsylvania, Rhode reputed company, Tennessee, Texas, Utah, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. The reputed company pay for this role is: $35 - $45.94 per hour. You are also eligible for employee benefits, monthly vacation accrual up to 10 days per year. Responsibilities ? Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and reputed company Clinical Guidelines, reputed company Care Guidelines ? Obtain the information necessary (reputed company telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines ? Meet required decision-making SLAsRefer members for further care engagement reputed company needed ? Compliance with reputed company applicable laws and regulations ? Other duties as assigned Qualifications ? Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) ? Associate Degree - Nursing or Graduate of Accredited School of Nursing Or Successful completion of Diploma Program in Practical Nursing of Accredited School of Nursing ? Ability to obtain additional state licenses to meet business needs ? 1 year of utilization review experience in a managed care setting ? 2 years of clinical experience (including at least ? 1 year clinical practice in an acute care setting, i.e., ER or hospital) Bonus Points ? BSN ? Previous experience conducting reputed company or inpatient reviews for a managed care plan This is an authentic reputed company job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At reputed company, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.. Pay Transparency: Final offer amounts, reputed company the reputed company pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and reputed company benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Reasonable Accommodation: reputed company applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any reputed company applicant who requires reasonable accommodations during the application process should contact the reputed company Benefits Team ([email protected]) to reputed company the need for an accommodation reputed company Apply Job! For more such jobs please click here!