100% remote Appeals Nurse (Oregon RN License required)

Job Description
• Research and Investigate member and/or provider appeals and grievance requests, includes review of UM/claim denial reasons, contract/regulatory rules, benefits and documentation received on appeal/grievance.
• Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance. Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions.
• Prepares case file (original denial, all information received on appeal, medical records, etc.).
• Schedule participant/member for committee panel sends scheduling letter if needed.
• Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings.
• Prepare and send case files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.).
• Communicates updates and status of outstanding member and provider complaints/issues to management.
• Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures.
• Update and/or generate authorization updates requests, for services that have been appealed.
• Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue.
• Maintains quality and compliance standards as dictated by the state and federal entities
• Maintains contractual agreements with participating providers related to appeals and grievances.
• Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk.
• Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management.
• Obtain authorization for release of sensitive and confidential information.
• Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances.
• Ensure case file is sent to the appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates.
• Provide support presenting cases and facilitating committee meetings as needed.
• Send appeal to an independent review organization portal, for those appeals that require an external match specialty review.
• Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained,
• Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed.
• Creates a decision letter with detailed description of the nature of appeal / grievance including rationale for the decision and options for moving forward.
• Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances.
• All other duties as assigned

Job Types: Part-time, Contract

Pay: $40.00 per hour

Expected hours: 20 – 32 per week

Medical Specialty:
• Medical-Surgical

Physical Setting:
• Acute care

Experience:
• Appeals and Grievances experience on the payor side: 2 years (Required)

License/Certification:
• RN License in Oregon (Required)

Work Location: Remote

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