Nurse Appeals (US)

Nurse Appeals (US)

Nurse Appeals- Licensed Nurse

Location: Mason, OH; Cincinnati OH; Indianapolis, IN; Louisville, KY; Norfolk, VA and Richmond, VA

Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Hours: The work schedule for this position is Tuesday through Saturday with Sunday rotation. Business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8-hour shift between those hours, including holidays on a rotational basis.

Nurse Appeals is responsible for investigating and processing medical necessity appeals requests from members and providers.

How you will make an impact:

• 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.
• Utilizes 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.

Minimum requirements:

• Requires a HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.

Preferred Skills, Capabilities and Experiences:

• AS or BS in Nursing preferred.
• Three to five years of clinical experience as a Registered Nurse strongly preferred.
• Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred.
• Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred.
• Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred.
• Experience with Facets, Macess, and ACMP is preferred.

Job Level: Non-Management Exempt

Workshift: Job Family: MED > Licensed Nurse