Clinical Appeals RN

Primary Responsibilities

• Represent MassHealth at appeal hearings
• Defend MassHealth prior authorization decisions by utilizing program specific regulations, medical necessity guidelines, standards of care and best practices
• Represents the MA MLTSS program in a positive, solution-focused manner that embodies our corporate values: Integrity, Compassion, Relationships, Innovation and Performance
• Determine the appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
• Identify solutions to non-standard requests and problems
• Participate in regular meetings to collaborate with supporting leadership and team to ensure operational efficiency
• Affirms performance adheres with established quality standards, evidenced based practice guidelines and departmental benchmarks and workflows
• Act as a resource for others; provide explanations and information on difficult issues

Requirements

• Associate's degree in Nursing
• Unrestricted RN license required in the state of Massachusetts
• 3+ years of Managed Care and/or clinical experience
• Designated workspace and access to install secure high-speed internet via cable or DSL in home
• Reside in the state of Massachusetts

Qualifications

• 10% travel within the state of MA

Preferred Qualifications

• Prior-Authorization experience
• Utilization Management experience
• Appeals Experience
• Medicare/Medicaid experience preferred
• Proficient with Microsoft Office programs, including Word, Excel, PowerPoint
• Excellent communications skills, including the ability to write clearly, succinctly and in a manner that appeals to a wide audience
• Excellent time management, organizational, and prioritization skills with ability to balance multiple priorities