This is a part-time role with 20-hour work weeks. The schedule must be consistent once agreed upon, with options to work 5 hours per day for 5 days a week or 3 days a week to reach 20 hours.
Responsibilities:
Prepare case reviews for Medical Directors by researching appeals, reviewing criteria, and analyzing the appeal basis.
Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards.
Communicate with members, providers, facilities, and other departments regarding appeal requests.
Generate appropriate appeals resolution communication and reporting for members and providers in accordance with company policies, State, Federal, and NCQA standards.
Work with leadership to increase the consistency, efficiency, and appropriateness of responses to all appeal requests.
Partner with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
Perform other duties as assigned.
Comply with all policies and standards.
Requirements:
Education/Certification: Associate in nursing, Bachelor’s in nursing or higher preferred.
Licensure: RN, LPN required; LVN preferred.
Must have Medicare knowledge, InterQual or Milliman experience, and clinical reviews for Utilization Management or Appeals.
Disqualifiers include not having a valid/active RN/LPN license.