Temporary A&G RN

HealthEdge•Remote,

4d•Remote

About The Position

The A&G RN independently processes assigned transactions accurately and efficiently within applicable service-level agreements, clarifies complex transactions for others, and maintains the quality and accuracy of work. The role investigates and processes complex member and provider grievances and appeals, reviews services for medical necessity, and prepares documentation in accordance with applicable regulatory and accreditation standards. The nurse recommends whether appeals should be upheld or denied and coordinates further review with the Medical Director. The position also documents case information, drafts correspondence, and serves as a subject matter expert on appeals, grievances, and quality-of-care issues. The role is temporary and contract, and is remote in the United States. Weekend transaction support may be needed based on business needs. The work may involve operating across time zones, extended periods at a computer, occasional movement around an office, and travel depending on company needs.

Requirements

Unrestricted USRN mainland license.
At least 2 years of experience in utilization management or review.
Clinical knowledge and experience related to patient care and healthcare delivery processes.
Excellent written and verbal communication skills.
Excellent customer service and interpersonal skills.
Working knowledge of current Microsoft Office Suite PC applications.
Ability to apply clinical criteria and guidelines for medical necessity, setting or level of care, and concurrent patient management.
Knowledge of current standard medical procedures and practices, trends and developments in medicine and nursing, alternative care settings, and levels of service.
Knowledge of applicable accreditation standards and local, state, and federal regulations.
Appeals and grievance experience.
Strong problem-solving, facilitation, and analytical skills.
Flexibility to work with globally distributed teams and provide business-need support for weekend transactions.

Nice To Haves

Medicare Advantage experience.

Responsibilities

Independently process assigned transactions accurately and efficiently within applicable service-level agreements.
Investigate and process complex grievances and appeals requests from members and providers.
Review inpatient, outpatient, ambulatory, and ancillary services for medical necessity.
Review, research, and prepare appeals and grievances documentation in accordance with local, state, and federal regulations and designated accreditation standards, such as NCQA.
Prepare recommendations to uphold or deny appeals and work with the Medical Director on further review.
Document and log appeal and grievance information in relevant tracking systems.
Generate written correspondence to providers, members, and regulatory entities.
Serve as a subject matter expert on appeals, grievances, and quality-of-care issues.
Use leadership skills and assist with or perform other relevant essential functions as required.
Support weekend transactions when required by business needs.