Clinical Appeals Nurse

System One; Pittsburgh (Allegheny County); Remote; USD 65,000 - 85,000; Full time

Job summary

A leading company is seeking a Clinical Appeals Nurse for a 6-month remote contract. The role involves managing clinical appeals and state hearings, requiring an RN license and relevant experience. Strong communication and problem-solving skills are essential.

Qualifications

• Bachelor’s degree and RN License required.
• Managed care and Medicaid experience preferred.

Responsibilities

• Complete clinical appeals and state hearings from all states.
• Review and complete provider and member clinical appeals.
• Attend assigned State Hearings and ensure compliance.

Skills

Communication

Time Management

Problem Solving

Customer Service

Critical Thinking

Education

Bachelor’s degree in Finance, Business, Economics, Engineering

RN License

Associates Degree or equivalent years of relevant experience

Tools

Microsoft Office

Facets

Job description

Title: Clinical Appeals Nurse
ALTA is supporting a 6-month contract opportunity working 100% remote.

ALTA IT Services is a wholly owned subsidiary of System One, a leading provider of specialized workforce solutions and integrated services. ALTA is an established leader in IT Staffing and Services, for both government and commercial enterprises across the United States, specializing in Program & Project Management, Application Development, Cybersecurity, Data & Advanced Analytics, and Agile Transformation Services.

The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.

Essential Functions:

• Responsible for the completion of clinical appeals and state hearings from all states
• Review and complete all provider clinical appeals within required timeframes
• Review and complete member clinical appeals within required timeframes
• Review all information necessary to prepare State Hearing packets
  Communicate with state agencies and internal departments to prepare for State Hearings
• Attend assigned State Hearing and complete all required compliances
• Complete required compliances for Administrative Hearing decisions
• Apply ClientMedical Policy and Milliman guidelines when processing clinical appeals
• Issue notification letters to providers and members
• Issue administrative denials appropriately
• Refer denials based on medical necessity to medical director
• Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates
• Conduct monthly, quarterly, and ad hoc appeals reporting
• Collaborate with the Quality Improvement and Clinical Operations Team
• Lead to prepare all requests for Independent External Review
• Ensure compliance with regulatory and accrediting requirements
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree in Finance, Business, Economics, Engineering or
• RN License required
• Associates Degree or equivalent years of relevant experience required
• Managed care, appeals, and Medicaid experience preferred
• Utilization review experience is strongly preferred

Competencies, Knowledge and Skills:

• Intermediate proficiency with Microsoft Office products and Facets
• Knowledge of NCQA, URAC, OAC, and MDCH regulations
• Strong written and oral communication skills
• Ability to work independently and within a team environment
• Critical listening and thinking skills
• Proper grammar usage
• Time management skills
• Proper phone etiquette
• Customer Service oriented
• Decision making/problem solving skills
• Familiarity of healthcare field
• Knowledge of Medicaid
• Flexibility
• Change resiliency

Licensure and Certification:

• Current, unrestricted license as a Registered Nurse (RN) is required
• MCG Certification is required or must be obtained within six (6) months of hire

Ref: #860-IT Cincinnati