Appeals & Grievances RN (PA or NJ Licensed)

Position Responsibilities

• Specific Consider, review and evaluate cases in compliance with state and federally mandated turn-around-times and process requirements
• Ensure that all necessary clinical information is available to allow for a full and fair review
• Outreach as necessary to provider/provider staff for clarification or additional information needed
• Prepare claims and case summary for MD review and appropriate decision
• Ensure rationales are appropriate and supported by guidelines in accordance with regulatory requirements
• Access and review various resources to support denial or overturn denial
• General Perform daily work with a focus on the core principles of managed care: Patient Education, Wellness and Prevention Programs, Early Screening and Intervention & Continuity of Care
• Work proactively to expedite the care process
• Identify priorities and necessary processes to triage and deliver work
• Empower members to manage and improve their health, wellness, safety, adaptation, and self-care
• Assess and interpret member needs and identify appropriate, cost-effective solutions
• Identify and remediate gaps or delays in care/ services
• Advocate for treatment plans that are appropriate and cost-effective
• Work with low-income/ vulnerable populations to ensure access to care and address unmet needs
• Gather and evaluate clinical information to assess and expedite referrals within the healthcare system including consideration of alternate levels of care and services
• Facilitate timely and appropriate care and effective discharge planning
• Work collaboratively across the health care spectrum to improve quality of care
• Leverage experience/ expertise to observe performance and suggest improvement initiatives
• Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes
• Ensure individual and team performance meets or exceeds the performance competencies and metrics
• Contribute actively and effectively to team discussions
• Share knowledge and expertise, willingly and collaboratively
• Provide outstanding customer service, internally and externally
• Follow and maintain compliance with regulatory agency requirements

Qualifications

Competencies:

• Ability to translate member needs and care gaps into a comprehensive member centered plan of care
• Ability to collaborate with others, exercising sensitivity and discretion as needed
• Strong understanding of managed care environment with population management as a key strategy
• Strong understanding of the community resource network for supporting at risk member needs
• Ability to collect, stage and analyze data to identify gaps and prioritize interventions
• Ability to work under pressure while managing competing demands and deadlines
• Well organized with meticulous attention to detail
• Strong sense of ownership, urgency, and drive

Experience:

• Registered Nurse with current unencumbered Pennsylvania or New Jersey license
• Minimum of 5+ years of acute clinical experience
• Minimum 2 years experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.)
• 2+ years of appeals and grievance experience in managed care environment
• Strong knowledge of utilization management processes and industry best practice
• Indepth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual, etc.)
• Detailed knowledge and demonstrated competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care
• HMO and risk contracting experience preferred
• In-depth knowledge of current standard of medical practices and insurance benefit structures
• Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills
• Proficiency in Microsoft Office
• The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families
• Excellent analytical-thinking/problem-solving skills
• The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads
• The ability to offer positive customer service to every internal and external customer

Physical Requirements

• Must be able to sit in a chair for extended periods of time
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
• Must be able to fluently communicate both verbally and in writing using the English language

Pay & Schedule

• Expected Hours of Work: Friday 8am – 5 pm EST; with ability to adjust to Client schedules as needed
• Time Zone: Eastern or Central
• Salary Range: $70,000 - $100,000