The Nurse Appeals - Medicare is responsible for investigating and processing medical necessity appeals requests from members and providers. Responsibilities include conducting investigations and reviews of member and provider medical necessity appeals, reviewing prospective, inpatient, or retrospective medical records of denied services for medical necessity, extrapolating and summarizing medical information for medical director, consultants and other external review, preparing recommendations to either uphold or deny appeal and forwarding to Medical Director for approval, ensuring that appeals and grievances are resolved timely to meet regulatory timeframes, documenting and logging appeal/grievance information on relevant tracking systems and mainframe systems, generating written correspondence to providers, members, and regulatory entities, and utilizing leadership skills as a subject matter expert for appeals/grievances/quality of care issues and as a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues. The role is virtual full-time with required in-person training sessions. The team rotates to cover Saturdays and holidays. Minimum requirements include a HS diploma or equivalent with at least 2 years of experience in a managed care healthcare setting or equivalent combination of education and experience, and a current active unrestricted RN license to practice in applicable state(s) or territory of the United States. Preferred qualifications include a Bachelor degree in Nursing, strong critical assessment skills, understanding of Medicare regulatory guidelines, Medicare review experience, and strong oral, written, interpersonal communication, problem-solving, facilitation, and analytical skills. The position is non-management exempt, 1st shift in the United States, and part of the MED > Licensed Nurse job family.
