The Nurse Appeals will perform all or some of the following Job description:

• Conduct investigations and reviews of member and provider grievances and appeals

• Review prospective, concurrent or retrospective medical records of denied services for medical necessity

• Extrapolate and summarize essential medical information for medical director, consultants and other external review

• Prepare recommendations to either uphold or deny appeal and forward to Medical Director for approval

• Ensure that appeals and grievances are resolved timely to meet regulatory timeframes

• Document and log appeal/grievance information on relevant tracking systems and mainframe systems

• Generate appropriate written correspondence to providers, members, and regulatory entities.
   

• 2-3 years experience in a managed care healthcare setting, or any combination of education and experience, which would provide an equivalent background.

• Associates Degree in Nursing
• Current unrestricted RN license in applicable state(s)
• BSN preferred.
  
   
   
   

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