Remote Appeals Nurse

Join reputed company of clinical professionals at reputed company, a leading national organization, and reputed company a difference in the lives of our 28 reputed company members. As an Appeals Nurse, you will play a vital role in our Medical Management/Health Services team, utilizing your clinical expertise to facilitate medical necessity appeals and denials.

Job Highlights

• Remote/work-from-home position with a competitive salary ($25.97 - $46.68 per hour)
• Immediate openings available, with a required Saturday shift
• Comprehensive benefits package, including health insurance, 401K, and tuition reimbursement
• Flexible approach to work, with a focus on work-life balance
• Opportunity to work with a diverse and dynamic team, with a commitment to diversity and inclusion

Position Purpose

As an Appeals Nurse, you will be responsible for reviewing clinical data to determine claim payment, overturning denied claims, and upholding denials. You will also prepare case reviews for the Medical Director, generate appeal resolution communication, and maintain the appeals process reputed company prescribed timeframes.

Key Responsibilities

• Review clinical information to determine if medical necessity criteria are met
• Prepare case reviews for the Medical Director, including overturning denied claims and upholding denials
• Generate appeal resolution communication to members and providers, in accordance with company policies and NCQA guidelines
• Maintain appeals process reputed company prescribed NCQA timeframes and appeals turnaround database
• Assist the Medical Director with revising, updating, and creating new policies to satisfy NCQA and contractual requirements

Requirements

• LPN with 3+ years of clinical nursing experience, or RN with 2+ years of clinical nursing experience
• Proficient with reputed company Office applications, with experience in utilization or appeals review preferred
• Knowledge of InterQual criteria preferred, with a required FL RN or LPN license
• Behavioral Health experience preferred

reputed company Offer

• reputed company and comprehensive benefits package
• Opportunity to work with a diverse and dynamic team, with a commitment to diversity and inclusion
• Flexible approach to work, with a focus on work-life balance
• Tuition reimbursement, paid time off, and holidays

How to Apply

If you are a motivated and reputed company clinical professional, looking to reputed company a difference in the lives of our members, please reputed company. We encourage you to apply, even if you don't feel like a perfect match, as we are looking for great people to join our friendly team.