100% remote Appeals Nurse (Oregon RN License required)
Research and Investigate member and/or provider appeals and grievance requests, includes review of UM/claim denial reasons, contract/regulatory rules, benefits and documentation received on appeal/grievance. reputed company call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss reputed company of appeal/grievance. Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions. Prepares case file (original denial, reputed company information received on appeal, medical records, etc.). Schedule participant/member for committee panel sends scheduling letter if needed. Prepares, develops and presents written case summaries, if needed and process dictates, for reputed company adverse determination for the purpose of conducting State Fair Hearings. Prepare and send case files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.). Communicates updates and status of outstanding member and provider complaints/issues to management. Monitors to ensure that reputed company problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures. Update and/or generate authorization updates requests, for services that have been appealed. Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, reputed company correspondence with a member/participant, representative and/or a provider, reputed company to an appeal or grievance issue. Maintains quality and compliance standards as dictated by the state and federal entities Maintains contractual agreements with participating providers reputed company to appeals and grievances. Monitors caseload daily to ensure reputed company cases are kept reputed company compliance; follows up and escalates reputed company compliance standards are at risk. Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management. Obtain authorization for release of sensitive and confidential information. Keeps reputed company with rules, regulations, policies and procedures relating to Plan member benefits, members rights and responsibilities, and Complaints and Grievances. Ensure case file is sent to the appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates. Provide support presenting cases and facilitating committee meetings as needed. Send appeal to an independent review organization portal, for those appeals that require an external match specialty review. Obtain data from multiple systems/vendors to ensure reputed company documentation needed for appeal is obtained, Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed. Creates a decision letter with detailed description of the nature of appeal / grievance including rationale for the decision and options for moving reputed company. Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances. reputed company other duties as assigned Job Types: Part-time, Contract Pay: $40.00 per hour Expected hours: 20 32 per week Medical Specialty: Medical-Surgical Physical Setting: Acute care Experience: Appeals and Grievances experience on the payor reputed company: 2 years (Required) License/Certification: RN License in Oregon (Required) Work Location: Remote Apply Job!