Remote Appeals RN: Utilization & Grievance Expert

HealthEdge Software, Inc.; Stati Uniti; Remoto; USD 65.000 - 90.000; Part-time

Descrizione del lavoro

HealthEdge Software, Inc. is seeking a contract-based professional to manage complex grievances and appeals for members and providers in a remote US-based role.

The candidate will review medical necessity across inpatient, outpatient, and ancillary services and prepare documentation for regulatory and accreditation standards. The position requires a USRN license, at least 2 years in utilization management, strong communication, and the ability to work across time zones in a distributed team,

Competenze

• Unrestricted USRN mainland license.
• At least 2 years experience in utilization management / review.
• Medicare Advantage experience an advantage.
• Excellent written and verbal communication skills.
• Excellent customer service and interpersonal skills.
• Working knowledge of current industry Microsoft Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management.
• Knowledge of applicable accreditation standards, and local, state, and federal regulations.
• Appeals and grievance experience required.
• Flexible to work in globally distributed teams and on business need support weekend transactions.

Mansioni

• Investigate and process complex grievances and appeals requests from members and providers
• Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity
• Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards
• Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review
• Document and logs appeal/grievance information on relevant tracking systems
• Generate written correspondence to providers, members, and regulatory entities
• Serve as a subject matter expert for appeals, grievances, and quality of care issues
• Utilize leadership skills
• Assist with or perform other relevant essential functions as required

Conoscenze

Communication

Customer service

Interpersonal skills

Problem solving

Analytical skills

Facilitation

Clinical criteria application

Microsoft Office

Formazione

USRN license

Strumenti

Microsoft Office Suite

Descrizione del lavoro

HealthEdge Software, Inc. is seeking a contract-based professional to manage complex grievances and appeals for members and providers in a remote US-based role.

The candidate will review medical necessity across inpatient, outpatient, and ancillary services and prepare documentation for regulatory and accreditation standards. The position requires a USRN license, at least 2 years in utilization management, strong communication, and the ability to work across time zones in a distributed team,