Grievance and Appeals RN - Remote must reside in Indiana

Professional Management Enterprises•Indianapolis, IN

2h•$90,000 - $95,000•Remote

About The Position

Responsible for investigating and processing the most complex grievances and appeals requests from members and providers. This role involves reviewing medical records, preparing recommendations, ensuring timely resolution of appeals, documenting information, and serving as a subject matter expert for appeals, grievances, and quality of care issues.

Requirements

2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.
Behavioral Health experience
Current active unrestricted RN license to practice as a health professional within the scope of licensure in IN
Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
MCG (Milliman Care Guidelines) experience

Nice To Haves

CMCN (Certified Managed Care Nurse) certification strongly preferred
AS required/BS in Nursing preferred.

Responsibilities

Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
Generates written correspondence to providers, members, and regulatory entities.
Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.