Appeals and Grievances – Registered Nurse

COPE Health Solutions

5d • $85,000 - $95,000 • Remote

About The Position

Resolves grievances, appeals and external reviews for one Health Plan LOBs. Ensures regulatory compliance, timeliness requirements set by regulatory agencies, and accuracy standards are met. Coordinates efficient functioning of day-to-day operations according to defined processes and procedures. Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Completes responsibilities within defined deadlines, so as to avoid negatively impacting Operations. Assists with collecting and reporting data.

Requirements

• Compact Licensed RN required - California and New York State licensure preferred
• Bachelor’s degree in nursing preferred; Associate degree in nursing is minimum requirement.
• Knowledge of Medicare and Medicaid regulations
• Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills.
• Working knowledge of Microsoft Excel, Power-Point, and Word and strong typing skills
• Knowledge of Medicaid and/or Medicare regulations
• Knowledge of Milliman criteria (MCG)
• For UM Only: Previous Managed Care Organization or Health Plan experience.
• 3 years previous experience working in Appeals and Grievances
• Experience working with community-based organizations in underserved communities
• Working knowledge of the following required: Principles of utilization management; care management principles; basic knowledge of health plan contracts and benefit eligibility requirements; Hospital structures, Managed Care and payment systems
• Timely and accurate documentation of day-to-day activities in designated technology platform
• Adaptable to new technologies and software
• Proficiency in EMR system(s), Outlook and data entry experience preferred
• Basic PC skills (MS Word/Outlook/PPT/Excel)

Responsibilities

• Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements.
• Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems, focusing primarily on issues of medical necessity, quality of care, long term services and supports, etc.. Consults with the member, family, providers and health plan departments as necessary. Identifies and communicates key points from details.
• Investigates and coordinates the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, accurate and timely follow up is completed and activities are documented as required.
• Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan’s fiduciary responsibilities. Prepares records for physician review as needed.
• Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements.
• Coordinates external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations.
• Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals. Consults with enrollees, providers and the Medical Director, as appropriate.
• Provides input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service.
• Reviews information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria.
• Enters data and assists with compiling reports and analysis on the grievance and appeals process.
• Provides timely case completion with strict adherence to required regulatory and department timeframes, which may require after hours and weekend scheduled work.
• Works outside of regularly scheduled hours, as needed for timely case resolution, or as scheduled for coverage purposes by department management.

Benefits

• We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities and a paid parental leave program.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree