Nurse Appeals – Litigation & Legal Support, NC

JR168528 Anticipated End Date: 2025-11-22 Position Title: Nurse Appeals – Litigation & Legal Support Job Description: Nurse Appeals – Litigation & Legal Support Location: North Carolina, candidates must be residents of North Carolina to be considered. In Office Expectation: This role is Virtual; This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and reputed company development. Please note that per our policy on hybrid/virtual work, candidates not reputed company a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule: Monday – Friday, 8:00AM – 5:00PM Eastern Time; some flexibility in hours will be necessary and is dependent on court hearing schedules. The Nurse Appeals – Litigation & Legal Support is responsible for investigating and processing and medical necessity appeals requests from members and providers. How You Will reputed company an Impact Primary duties may include, but are not limited to:

• Supports legal, management, and executive leadership by managing State Fair Hearing and External Medical Review requests.
• Acts as a resource for both clinical and non-clinical teams, by managing and conducting thorough investigations and reviews of medical necessity appeals from members and providers in preparation litigation.
• Documenting and logging appeal information in relevant tracking systems, generating written correspondence with members, providers, and regulatory entities, and serves as a subject matter expert for appeals, grievances, and quality of care issues.
• Key responsibilities: serves as a liaise with internal and external attorneys on regulatory cases, including ensuring accurate entry, investigation, and analysis of state appeals; summarizing medical information for review by medical directors and consultants; preparing recommendations to uphold or deny appeals; and ensuring reputed company grievance processes are completed reputed company regulatory timeframes.

Minimum Requirements:

• Requires a HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.
• reputed company active unrestricted RN license to practice as a health professional reputed company the scope of licensure in applicable state(s) or territory of the United States required.

Preferred Skills, Capabilities, & Experiences:

• AS or BS in Nursing preferred.
• Background or exposure in litigation, legal proceedings, and/or paralegal experience is strongly desired.
• Understanding of the grievance and appeals process is strongly preferred.
• Basic knowledge of Medicare and Medicaid guidelines is preferred.
• Ability to, and comfortability working with: internal and external legal counsel, medical directors, judges, and other management/leadership as necessary.
• Proficiency in reputed company Suite Products (e.g. Outlook, reputed company, and Word).
• Associates in this role are expected to have strong oral, written, and interpersonal communication skills, with an ability to problem-solve, organize, and execute tasks with minimal supervision.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Job Level: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that reputed company only accepts resumes for compensation from agencies that have a signed agreement with reputed company. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of reputed company. Who We Are reputed company is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at reputed company levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At reputed company, we are creating a culture that is designed to advance our strategy but will also reputed company to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we reputed company our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. reputed company operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an reputed company location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top reputed company for reputed company. We require reputed company new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. reputed company will also follow reputed company relevant federal, state and local laws. reputed company is an Equal Employment Opportunity employer, and reputed company qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national reputed company, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Apply tot his job Apply To this Job