Clinical Appeals Nurse

We're building a world of health around every individual , shaping a more connected, convenient, and compassionate health experience.

Responsible for intake, investigation, and resolution of appeals, complaints, and grievances scenarios for all products. You will ensure timely, customer-focused responses to appeals, complaints, and grievances, identifying trends and emerging issues, and recommending solutions.

Key responsibilities:

• Review and resolve clinical documentation, clinical complaints, and appeals
• Interpret data from clinical records, applying clinical criteria and policies in line with regulatory and accreditation requirements
• Coordinate clinical resolution with internal/external clinician support as required
• Gather data from multiple system applications, contacting providers, vendors, or internal departments as needed
• Apply comprehensive knowledge of complex delegation arrangements, coding logic, contracts, clinical criteria, benefit plan structure, and regulatory requirements
• Condenses complex information into a clear clinical picture, working independently
• Collaborate with members, providers, regulators, and internal/external consultants
• Report findings, respond to rebuttal issues, and make recommendations for improvement
• Identify trends and emerging issues, reporting and giving input on potential solutions

Requirements:

• Unrestricted active nursing license
• 3-5 years of clinical experience, with 3-5 years of Behavioral Health Experience
• Excellent verbal and written communication skills, with excellent customer service skills
• Experience in reading or researching benefit language

Preferred qualifications:

• Managed Care experience

Education:

• RN with current unrestricted state licensure required

Benefits:

• Comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources

Salary range: $54,095.00 - $116,760.00 per year