RN Case Manager- Appeals

Healthcare Support Staffing; Sacramento (CA); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Fun and positive work environment

Job summary

A leading healthcare staffing firm is seeking a detail-oriented individual for managing medical necessity appeals and claims reviews. The role involves reviewing cases, preparing documentation for the Medical Director, and ensuring compliance with NCQA guidelines. Candidates should have strong computer skills, experience in utilization review or claims appeals, and effective written communication abilities. This position offers a positive work environment and competitive opportunities for career advancement.

Qualifications

• Proficient working on a computer.
• Experience with utilization review or claims appeals.
• Effective written communication skills.

Responsibilities

• Manage medical necessity appeals and denials.
• Review cases and determine appropriate actions.
• Prepare case reviews for the Medical Director.
• Generate communication regarding appeal resolutions.
• Gather information for Administrative Law Hearings.

Skills

Computer proficiency

Utilization review experience

Strong written communication

Job description

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career!

Job Description

Daily Responsibilities

• This candidate needs to be comfortable in an office setting. The hiring manager wants to stay away from candidates coming straight from clinical as they are not used to a desk job and no patient interaction.
• This person will be reviewing cases to make sure the correct medical actions were taken and denying and appealing those cases. They will be writing letters and correspondence and sitting at a computer all day.
• Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met.
• Review clinical data to determine claim payment based on company policies and
• National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review.
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received.
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions.
• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution.
• Gather and prepare case information for Administrative Law Hearings.
• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database.
• Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements.

Qualifications

• Computer savvy is a MUST! – Candidates must be proficient working on the computer.
• Experience with utilization review or claims appeals.
• Well spoken – candidates will be writing letters and correspondence.

Hours for this Position:

Advantages of this Opportunity

• Fun and positive work environment.

Additional Information

Are you a RN with Case Management experience in appeals/Denials? If so please call me; Ashley directly 407-478-0332 ext 169. If you know anyone, we pay generously for referrals!