Nurse Appeals RN-Quality of Care

Nurse Appeals

Job Description: Nurse Appeals RN-Quality of Care

Must reside in the state of Louisiana.

Locations: Metairie, LA; Baton Rouge, LA; New Orleans, LA and Lafayette, LA

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.

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

How you will make an impact:

Primary duties may include, but are not limited to:

• Conducts investigations and reviews of member grievances and Quality of Care cases.
• Reviews medical records for member grievance concerns and Quality of Care cases.
• Extrapolates and summarizes medical information for medical director
• Prepares nurse summaries for Quality of Care cases and forwards to Medical Director for review and determination.
• Ensures grievances are resolved timely to meet regulatory timeframes.
• Documents and logs 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 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.
• Multi-state/compact RN license preferred.
• Strong computer and Microsoft skills is strongly preferred.

Job Level: Non-Management Exempt

Workshift:

Job Family: MED > Licensed Nurse