Medicare Advantage Appeals And Grievance - Registered Nurse - Work At Home

Are you interested in learning about healthcare professions and the latest healthcare innovations in the KC area? Become part of an organization that is dedicated to making a difference in both your career and community.

Job Description Summary :

Job Description

• Maintains a thorough understanding of Health Plan operations and business unit processes, workflows and system requirements, including, but not limited to, plan benefits, authorizations, referrals, network and non-network provider claims, and regulatory compliance.
• Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
• Participates in CMS and other audits and related activities as required.
• Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations.
• Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each day.
• Acts as a member advocate addressing member or provider concerns
• Reviews medically appropriate clinical guidelines and prepares cases for Medical Director and/or External Review
• Develops timely and professional documentation and correspondence that ensures accuracy, completeness and conformance to quality and regulatory standards
• Formulates determination language that resolves member or provider issues in a manner consistent with regulatory and accrediting agency requirements
• Recognizes potential quality of care concerns
• Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals.
• Provides training, leadership and mentoring for less experienced appeal RN and administrative staff.
• Utilizes multiple internal and external computer applications and programs
• Meets established productivity and quality standards
• Performs other duties as assigned

Minimum Qualifications

• State of Missouri & Kansas Licensure
• Active, unrestricted Registered Nurse License
• Associates degree in Nursing Required
• Minimum of 2-3 years of appeals and UM experience in a payer-based environment

• Minimum of 3 years of acute care or outpatient clinical experience
• Strong critical thinking, analytical, research and organizational skills
• Knowledge of CMS, URAC, NCQA® , state and federal regulations/guidelines
• Knowledge of MCG, InterQual or other medically appropriate clinical guidelines
• Excellent written and oral communication skills
• Proficiency with PC-based software programs including Word, Excel and Outlook

Preferred Qualifications

• Bachelor’s degree in Nursing preferred 
• Multi – state licensure