Clinical Appeals RN

About the role

As a Clinical Appeals RN, you play a vital role in ensuring fair, accurate, and timely review of healthcare service and coverage denials. This role is critical in maintaining compliance with state and federal requirements while upholding the integrity of the appeals process.

Responsibilities

• Evaluate denied service authorizations and claims for medical necessity, appropriateness and compliance with clinical criteria
• Review and analyze medical records and clinical supporting documentation, making recommendations as to whether the denial should be overturned
• Collaborate with MVP Medical Directors, Utilization Management and Case Management to ensure alignment with MVP's medical policies
• Using clinical judgment, present clinical rationale/recommendation to MVP Medical Directors and external consultants for review and determination
• Ensure compliance with State and Federal regulations, including accreditation requirements (e.g.: CMS, Medicaid, NCQA)
• Maintain accurate and up-to-date records of appeals, including documentation of all communication in the department's tracking system
• Monitor and track status of appeals, ensuring cases are processed within specified timeframes
• Identify opportunities for process improvement and contribute to the development and implementation of best practices
• Analyze appeal outcomes to identify trends, patterns, issues with denials, recommending process improvement

Requirements

• Active, unrestricted RN license in good standing
• Graduate of an Accredited nursing program required (BSN preferred)
• Minimum 3-5 years of clinical nursing experience
• Strong knowledge of medical terminology, healthcare procedures, and clinical guidelines
• Previous experience in clinical appeals, utilization management or managed care and LTSS is highly desirable
• Exceptional customer service skills and ability to handle difficult situations with empathy and professionalism
• Strong attention to detail and ability to manage multiple tasks simultaneously
• Ability to work independently and as part of a team in a fast-paced environment

Qualifications

• Strong clinical expertise
• Attention to detail
• Able to manage multiple cases in a fast-paced environment

Skills

• Strong knowledge of medical terminology, healthcare procedures, and clinical guidelines
• Previous experience in clinical appeals, utilization management or managed care and LTSS is highly desirable
• Exceptional customer service skills and ability to handle difficult situations with empathy and professionalism
• Strong attention to detail and ability to manage multiple tasks simultaneously
• Ability to work independently and as part of a team in a fast-paced environment

Benefits

• Growth opportunities to uplevel your career
• A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team
• Competitive compensation and comprehensive benefits focused on well-being
• An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace

Pay

The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role. We do not request current or historical salary information from candidates.

$69,383.00-$92,279.00