Remote Claims Review Nurse / Clinical Appeals Nurse | WFH

Job Overview

We are actively seeking a dedicated Clinical Appeals Nurse to oversee clinical appeals and manage state hearings across various regions. This remote position entails the comprehensive review and processing of appeals, ensuring adherence to strict timelines and accuracy, while collaborating with diverse teams and agencies to facilitate the appeals process effectively.

Key Responsibilities

• Manage the completion of clinical appeals and state hearings across all states
• Review and process clinical appeals from providers and members within designated timeframes
• Compile vital information for preparing State Hearing packets
• Engage with state agencies and internal departments to ensure thorough preparation for hearings
• Participate in State Hearings, ensuring compliance with all necessary regulations
• Address decisions from Administrative Hearings in accordance with guidelines
• Apply relevant medical policies and Milliman guidelines during clinical appeal processing
• Issue notification letters to providers and members as required
• Appropriately manage administrative denials and refer medical necessity denials to the Medical Director
• Maintain precise documentation in both digital and hardcopy systems, achieving an accuracy rate of 90-95%
• Generate regular reports on appeals, including monthly, quarterly, and ad hoc reports
• Collaborate with Quality Improvement and Clinical Operations teams for Independent External Review requests
• Ensure compliance with regulatory and accrediting standards
• Undertake additional responsibilities to support the team and department as needed
  
  

Required Skills

• Proficiency in Microsoft Office and Facets
• Familiarity with NCQA, URAC, OAC, and MDCH regulations
• Exceptional written and verbal communication capabilities
• Ability to work independently and collaboratively within a team environment
• Strong critical thinking and listening skills
• Proficient in proper grammar usage
• Effective time management and professional phone etiquette
• Customer service-oriented, focusing on meeting the needs of both providers and members
• Strong decision-making and problem-solving skills
• Substantial understanding of the healthcare landscape, particularly Medicaid
• Flexible and adaptable, capable of managing changing priorities
  
  

Qualifications

• Active Registered Nurse (RN) License is required
• Associate's Degree or equivalent relevant experience is necessary
• Preferred: Experience in managed care, appeals, and Medicaid
• Strongly Preferred: Experience in utilization review
  
  

Career Growth Opportunities

Our organization is committed to fostering professional growth. While specific advancement pathways may not be outlined, this role provides essential responsibilities that can lead to further opportunities in healthcare management.

Company Culture And Values

We pride ourselves on a collaborative company culture, where team-oriented individuals can excel. We emphasize effective communication, adaptability, and a commitment to delivering high-quality service in the healthcare sector.

Compensation And Benefits

We offer a comprehensive benefits package, including:

• Medical, dental, and vision insurance
• Health Savings Account (HSA)
• Life insurance
• Short-term and long-term disability coverage
• 401(k) plan
  
  

This is an exceptional opportunity for Registered Nurses looking to make a significant impact within the healthcare industry. Join us in shaping the appeals process and ensuring compliance with regulations while supporting the needs of providers and members.

Employment Type: Full-Time