About this role
Role Overview
- Investigate and process medical necessity requests from both members and providers
- Conduct and lead investigations and reviews for member and provider medical necessity appeals
- Review the medical record of denied services for medical necessity
- Provide a summary of case for the medical director and other partners in the health plan care team
- Ensure that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements
- Document and log case information for the appeal
- Generate the written response to the member or provider
- Serve as a subject matter expert for appeals and grievances
- Commit to a career of life-long learning and continuous improvement of processes related to Utilization Review
Requirements
- Current Registered Nurse license issued by the state
- OR Current Licensed Practical Nurse license issued by the state AND Three (3) years of clinical experience
- Three (3) years’ experience with clinical claims processing and review
- Three (3) years’ experience working with appeal and grievances
- Two (2) years’ customer service experience
- Bachelor of Science in Nursing (preferred)
- Medical Management experience (preferred)
Benefits
- Health insurance
- Retirement plans
- Paid time off
- Flexible work arrangements
- Professional development