Job Title: Appeals Nurse
Duration: 10 months contract (Possibility to extend)
Location: Remote, preferred Iowa Possible to work on-site (1080 Jordan Creek Pkwy, West Des Moines, IA 50266)
Shift Type: Mon-Fri 8am-5pm CST – No OT
Payrate: $30-33/hr
Responsibilities:
• Review clinical data to determine claim payment based on company policies and
• National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
• Gather and prepare case information for Administrative Law Hearings
• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
• Assist the Medical Director with revising, updating, and/or creating new policies to satisfy NCQA and contractual requirements.
Typical Day in the Role:
• Member appeal requests are received and assigned by the team lead, the appeals nurse is responsible for working the appeal start to finish.
• Outreach attempts are made to member/provider.
• A clinical review is completed and case sent to specialty review/MD.
• Appeals nurse will write determination letters and close the case.
• 30 calendar days to complete standard cases and 3 business days to acknowledge receipt of the case.
Requirements:
• LPN
• At least 2 years nursing experience, UM experience helpful
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