Appeals RN

Location: Schenectady, NY
Date Posted: 08-01-2018
Appeals RN – Health Plan
Schenectady, NY
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 6 months, or longer! ***

Appeals Nurse Job Summary:
  • Supports the organization by working to resolve provider payment disputes through advanced and complicated case review of the appropriateness of medical care requiring considerable clinical judgment, independent analysis, and detailed knowledge of managed care and organizational guidelines.   
  • Manages the consolidation of the complaints and grievance activities on a quarterly basis, and prepares monthly, quarterly and annual reports on assigned quality improvement activities.
  • Maintains strict compliance with federal, state and NCQA requirements and guidelines
Appeals Nurse Background:
  • Current, valid, and unrestricted state Registered Nurse (R.N.) license.
  • Bachelor’s of Science in Nursing (BSN) or related healthcare field is a plus.
  • At least 2-5 years acute care clinical nursing experience is required.
  • Around 2-4 years of recent experience at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • Roughly 1-2 years of experience handling Denials and/or Appeals and/or Grievances.  Case Management and/or Utilization Review experience will be considered in lieu of direct Appeals/Denials experience.
  • Direct experience with guidelines for Medicaid/Medicare and related state programs is required.
  • Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
  • Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
443.552.7423 (CALL – TEXT – FAX)

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