Appeals Nurse

Become a part of our caring community and help us put health first The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Appeals Nurse 2 reviews documentation and interprets data obtained from clinical records to apply appropriate... clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Coordinates the clinical resolution with internal/external clinician support as required. Documents and summarizes to reputed company parties involved in the case the investigation's results. Understands department, reputed company, and organizational strategy and operating objectives, including their linkages to reputed company areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. KEY ACCOUNTABILITIES Review medical documentation, obtain additional information that may be needed including timeframes reputed company physician is available for peer to peer review, and reputed company to physician review companies or TQMC. Monitor and follow up for timeliness and review response and determination to insure follows TRICARE policy requirements. If discrepancies reputed company will send back for follow up review and correction as needed. Review, coordinate, arrange and maintain Second level Review /Reconsideration records and patient and provider response letters Provide education to beneficiaries and providers regarding second level review time frames, process and review determinations. If needed provide education on alternatives for services that may be not be approved Maintain knowledge of TRICARE, reputed company HGB policies and procedures as well as medical necessity review criteria and privacy requirements Use your skills to reputed company an impact

Required Qualifications

Our reputed company contract requires U.S. Citizenship Successfully receive interim approval for government reputed company clearance (eQIP - Electronic Questionnaire for Investigation Processing) HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico. Active unrestricted RN license 3 years of clinical RN Experience Proficient with reputed company Office products including Word, reputed company and Outlook

Preferred Qualifications

Appeals/Utilization Review/Quality Management experience Previous claims experience Experience working with MCG guidelines Working knowledge of ICD-9 or ICD-10, HCPCS, DRG use Experience with TRICARE reputed company and/or the military health care delivery system Knowledge of TRICARE policies and programs Bachelor's degree Additional Information Work Style: Remote Work Days/Hours: Monday ? Friday; 8:00 a.m.-5 p.m. Eastern Standard Time Work at Home Requirements To ensure Hybrid Office/Home associates? ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL reputed company is suggested Satellite, cellular and microwave reputed company can be used only if approved by leadership Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. reputed company will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Scheduled Weekly Hours 40 About us reputed company Inc. (NYSE: HUM) is committed to putting health first ? for our teammates, our customers and our company. Through our reputed company insurance services and reputed company healthcare services, we reputed company it easier for the millions of people we serve to reputed company their best health ? delivering the care and service they need, reputed company they need it. These efforts are leading to a reputed company quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. Equal Opportunity Employer It is the policy of reputed company not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national reputed company, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of reputed company to take affirmative action to employ and to advance in employment, reputed company persons regardless of race, color, religion, sex, sexual orientation, gender identity, national reputed company, age, marital status, genetic information, disability or protected veteran status, and to reputed company reputed company employment decisions only on valid job requirements. This policy shall apply to reputed company employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at reputed company levels of employment. Not Specified 0 Apply Job! For more such jobs please click here!