Remote Utilization Review RN – Appeals & Grievances

HealthEdge; United States; Remote; USD 55,000 - 83,000; Part time

Job summary

HealthEdge is seeking a remote (US) Appeals & Grievances Specialist to independently process complex grievances and conduct medical necessity reviews across inpatient, outpatient, and ancillary services. You will prepare documentation for regulatory standards and coordinate with Medical Director for case outcomes.

Ideal candidates have an unrestricted USRN license, 2+ years in utilization management, and strong written/verbal communication.

Qualifications

• 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 accreditation standards, and local, state, and federal regulations.
• Appeals and grievance experience required.
• Strong problem-solving skills, facilitation skills, and analytical skills.
• Flexible to work in globally distributed teams and on business need support weekend transactions.

Responsibilities

• 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 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.

Skills

Utilization management

Communication skills

Customer service

Microsoft Office

Education

USRN license

Job description

HealthEdge is seeking a remote (US) Appeals & Grievances Specialist to independently process complex grievances and conduct medical necessity reviews across inpatient, outpatient, and ancillary services. You will prepare documentation for regulatory standards and coordinate with Medical Director for case outcomes.

Ideal candidates have an unrestricted USRN license, 2+ years in utilization management, and strong written/verbal communication.