Position Title: Appeals Nurse 
Work Location: Remote
Assignment Duration: 08 Months
Work Schedule: M-F 
Work Arrangement: Remote
Position Summary: 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

Background & Context:
Education/Experience: LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.

License/Certification: RN or LPN license.

For our organization only: NYS RN license required.

Key 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.

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 51.73/hr.