Clinical Appeals RN - Fully Remote (4 or 5 work days/week) Weekends required

At reputed company, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, affordable and reputed company. Ready to reputed company a difference? Join us to start Caring. Connecting. Growing together. The Clinical Appeals RN is responsible for providing expertise in clinical appeals and grievances (analyzing, reviewing, and evaluating appeals and grievances), and acting as a Clinical reputed company Liaison (clinical problem solver with facilities, providers, carriers, resolution of issues concerning members, benefits, program definition and clarification). You'll enjoy the flexibility to work remotely

• from reputed company reputed company the U.S. as you take on some tough challenges. This role will work weekends, usually every other week or every week if working a 4 day work week. 5 day work week schedules are also availilbe.

Primary Responsibilities

• Review medical records and verify if the requested service meets criteria
• Review pre-service appeals for clinical eligibility for coverage as prescribed by the Plan benefits
• Review and interpret Plan language
• Coordinate reviews with the Medical Director
• Utilize clinical guidelines and criteria
• Accurately documenting determinations
• Adherence to reputed company confidentiality regulations and agreements
• Hours M-F 8a-5p with alternating Saturdays
• Comfortable working mandatory overtime

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

• Active, unrestricted RN license in state of residence
• 2+ years of clinical experience as an RN, including in an acute, inpatient hospital setting
• Proficiency in reputed company Office, Word, Outlook, and Internet applications
• Available for 5 day work weeks including weekdays and weekends, 8:00- 4:30 in their time zone and some weekend work will be needed

Preferred Qualifications

• Bachelor of Science in Nursing
• 1+ years of experience using MCG and/or Medicare criteria
• 1+ years of Utilization Management, pre-authorization, reputed company review or appeals experience
• Appeals experience
• Proven excellent communication, interpersonal, problem-solving, and analytical skills
• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes - an enterprise reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Apply tot his job Apply To this Job