Clinical Appeals RN (Remote)

ALTA IT Services is staffing a contract to hire opportunity for a Clinical Appeals RN to support a leading health insurance customer. The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and Government Programs lines of business to formulate a professional response to the appeal request.

Pay: $46/HR

100% Remote

Must have: RN

Job Responsibility

• Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators.
• Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates.
• Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence.
• Formulates recommendations for disposition.
• Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights.
• Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate.
  
  

2 years experience in Medical Review, Utilization Management or Case Management.

BSN/MSN Degree

Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals., Proficient

Ability to effectively communicate and provide positive customer service to every internal and external customer., Advanced

Knowledge of Microsoft Office programs., Proficient

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