Appeals Nurse

Position Title: Appeals Nurse

Work Location: Remote - South Carolina

Assignment Duration: 6 Months with potential of extension or conversion

Work Schedule: 8-5 pm EST Mon - Fri

Position Summary: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met.

Background & Context: The Clinical Appeals team plays a vital role in supporting our organization's regulatory compliance, operational integrity, and member and provider experience. The team is responsible for timely and accurate review of provider disputes, member grievances, and appeals, with a strong focus on meeting State and NCQA requirements.

Key Responsibilities:

• Review clinical data to determine claim payment based on company policies and
• National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
• Gather and prepare case information for Administrative Law Hearings
• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
• Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements.

Qualification & Experience: