Nurse Appeals -Utilization & Case Management

Anticipated End Date:

Position Title:

Job Description:

Location: Virtual: This role enables associates to work virtually full-time, except for 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.

Hours: Business hours are 8 am to 5 pm CT

The Nurse Appeals is responsible for investigating and processing and medical necessity appeals requests from members and providers.

How you will reputed company an impact:

• Conducts investigations and reviews of member and provider medical necessity appeals.
• Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
• Extrapolates and summarizes medical information for medical director, consultants and other external review.
• Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
• Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
• Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
• Generates written correspondence to providers, members, and regulatory entities.
• Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.

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.
• Utilization management experience highly preferred.
• Case management experience strongly preferred.

Job Level:

Workshift:

Job Family:

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.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.