Job Title: Appeals Nurse

Duration: 10 months contract (Possibility to extend)

Location: Remote, preferred Iowa Possible to work on-site (1080 Jordan Creek Pkwy, West Des Moines, IA 50266)

Shift Type: Mon-Fri 8am-5pm CST – No OT

Payrate: $27-28/hr

Responsibilities:

• 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.

Typical Day in the Role:

• Member appeal requests are received and assigned by the team lead, the appeals nurse is responsible for working the appeal start to finish.

• Outreach attempts are made to member/provider.

• A clinical review is completed and case sent to specialty review/MD.

• Appeals nurse will write determination letters and close the case.

• 30 calendar days to complete standard cases and 3 business days to acknowledge receipt of the case.

Requirements:

• LPN

• At least 2 years nursing experience, UM experience helpful