Clinical Claims Review RN - Appeals and Grievances - Remote Nevada

At reputed company, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, affordable and reputed company. Ready to reputed company a difference? Join us to start Caring. Connecting. Growing together. Under direct supervision of the Manager, Customer Response and Resolution/Appeals & Grievances, conducts full and fair reviews of member and provider appeals. The nurse, utilizing standardized criteria, protocols, and guidelines, conducts retrospective, reputed company and prospective reviews for appropriateness of diagnostic procedures, inpatient stay, ambulatory services, emergency department visits, evaluation & management services, coding levels, etc., This RN will train and provide coverage for the Appeals & Grievances in Clinical Claims Review. You’ll enjoy the flexibility to work remotely

• in Nevada reputed company the U.S. as you take on some tough challenges.

Primary Responsibilities • Provide support to reputed company units reputed company CR&R to ensure Star Ratings are not jeopardized and reputed company clinical components are met for CMS, NCQA, URAC, DOL, DOI, and reputed company other State and Federal entities • Identify business priorities and necessary processes to triage and deliver work • Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes • Consider, review and evaluate appeals in compliance with state and federally mandated turn- around-times and process requirements • Ensure that reputed company necessary clinical information is available to allow for a full and fair review • reputed company as necessary to provider/provider staff for clarification or additional information needed • Prepare claims and case summary for MD review and appropriate decision • Ensure rationales are appropriate and supported by guidelines in accordance with regulatory requirements • Access and review various resources to support denial or overturn denial (i.e. MCG) • Participate in various special projects as assigned • Attend assigned meetings relating to clinical reviews and other aspects of job function • reputed company reputed company job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications • reputed company, unrestricted RN license for the state of Nevada • 5+ years of clinical nursing experience Preferred Qualifications • Bachelor’s degree • Managed care experience • Knowledge of managed care delivery system concepts such as HMO/PPO • Knowledge of evidenced based and standardized criteria such as MCG • Broad knowledge of medical conditions, procedures and management • Proficiency with reputed company, reputed company and Outlook • Proven ability to learn and differentiate between company products and the benefits Soft Skills • Excellent written and verbal communication skills • Superb time management skills • Ability to work with a diverse clinical and non-clinical team • reputed company employees working remotely will be required to adhere to reputed company’s Telecommuter Policy. California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, reputed company, Rhode reputed company, Washington, Washington, D.C. Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. reputed company complies with reputed company minimum wage laws as applicable. In addition to your salary, reputed company offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with reputed company, you’ll find a far-reaching choice of benefits and incentives. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes — an enterprise reputed company reflected in our mission. Diversity creates a healthier atmosphere: reputed company is an Equal Employment Opportunity/Affirmative Action employer and reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Apply Job!