Overtime may be required and Holidays are required
Responsibilities:
Draft correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards.
Perform clinical review of outcomes including creating and editing denial letters based on denial determinations in accordance with NCQA standards.
Contribute to correspondence letter template creation and maintenance.
Investigate denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, providing supplemental information to resolve denial claims.
Assist with issues and/or questions related to correspondence with state, local, and federal agencies including third-party payers to ensure timely resolution.
Maintain and monitor cases to ensure timely resolution and appropriate documentation of actions and/or decisions.
Coordinate with interdepartmental teams on training needed within the utilization management team based on trends.
Provide feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices.
Perform other duties as assigned.
Comply with all policies and standards.
Requirements:
Graduated from an accredited school of nursing or A.D. or bachelor’s in nursing.
LPN or RN, active in any state.
Minimum 1 year of nursing experience.
Ability to critically think.
Ability to effectively use Microsoft OneNote and Word.
Ability to work remotely, i.e., meet production deadlines; quality metrics.