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Appeals Nurse-RN Reviewer
Ref No.: 18-29213
Location: Richmond, Virginia
Job Title: Appeals Nurse-RN Reviewer (Registered Nurse)
Duration: Temp to Hire
Location: Richmond, VA
The Appeal Nurse Reviewer is responsible for the resolution of clinical appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical and administrative criteria and policies in line with regulatory and accreditation requirements for member and provider appeals and disputes. Independently coordinates the clinical resolution with internal and external clinician and non-clinical and medical management support as required. Documents and summarizes to all parties involved in the case the investigations results.
Essential functions:
  • Communicates with medical office personnel to obtain pertinent clinical history and information. Documents and summarizes clinical or administrative rationale for all approvals and denials to all parties involved in the case.
  • Prepares State Fair Hearing (SFH) summaries, and may attend the SFHs to support the Medical Director
  • Implements quality assurance plans for specific contracts and coordinates this activity with the appropriate account managers or dedicated quality assurance staff.
  • Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews.
  • Participates in on-going training programs to ensure quality performance complies with applicable standards and regulations.
  • Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures.
  • Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan’s required timeframes.
  • Documents communications with medical office staff and/or MD provider as required.
  • Refers cases to appropriate internal reviewers according to the business needs of the particular health plan.
  • Researches requests for post-determination review and categorize each for processing based on the applicable health plan policies and procedures.
  • Reviews and coordinates documentation; interprets data obtained from clinical records and ensures appropriate clinical criteria and policies are aligned with regulatory and accreditation requirements for members and providers.
  • Tracks all post-determination cases to completion to ensure compliance.
  • Trains new employees on the appeals and de-certification process as needed.
  • Works closely with the appeals-dedicated Reviewers to ensure timely adjudication of processed appeals.
Other essential functions:
  • Gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies, and evidence-based medical necessity criteria.
  • Collects and analyzes utilization information. Assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity.
  • Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.
  • Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network.
  • As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
  • Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and policies, procedures and criteria.
  • Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence.
  • Participates in Care Coordination team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
  • Maintains an active work load in accordance with performance standards. Works with community agencies as appropriate.
  • Participates in network development including identification and recruitment of quality providers as needed.
  • Advocates for the enrollee to ensure health care needs are met.
  • Interacts with providers in a professional, respectful manner. Provides coverage of expedited cases that may fall on a weekend and/or holiday, as required for the position.
Must haves: Utilization Review and Quality, & Appeals
Duration: Temp to hire
Hours: Mon-Fri, flexible between 8a-5p (Will be onsite for a minimum probationary 30 days and then would be considered to work remote)
Degree: Bachelors required
Certification/ License: RN in the state of VA