Appeals and Grievances Nurse

It?s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary...
The Appeals and Grievances Nurse Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate recommendations involving grievance and appeal determinations, in collaboration with the Appeals and Grievances Department Staff and Medical Directors. The Appeals and Grievances Nurse is responsible for clinical support of all clinical appeals and grievance activities

Our Investment in You:

Full-time remote work

Competitive salaries

Excellent benefits

Key Functions/Responsibilities: Member Appeals and Grievances

Investigate medical necessity appeals and reviews prospective, inpatient, and retrospective medical records of denied services for medical necessity
Supports the grievance intake, investigation, and resolution processes and identifies trends and areas for improvement along with process improvement initiatives
Ensures clinical appeals and grievances are resolved in a timely manner
Prepare clinical reviews and provides monitoring of cases involving medical decisions and quality of services and care
Assist with written correspondence to providers and members
Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received.
Prepare case review for cases going to external review including coordinating the appropriate questions to include in the correspondence with the external review request
Communicates on behalf of the department with the peer review vendor providing consults for member appeals and acts as intermediary between vendor and Plan medical directors regarding case findings
Presents recommendations based on clinical review, criteria, and organizational policies
Complies with HIPAA and other compliance requirements to protect patient confidentiality
Contact and educate members and guarantors regarding necessary steps to resolve outstanding appeals
Is familiar with compliance requirements with contractual, regulatory and accreditation bodies
Maintains current knowledge of regulatory, contractual and accreditation requirements subject matter expert
Acts as Liaison with Quality in forwarding potential quality of care grievances for investigation
Other duties as assigned

Supervision Exercised:

None

Supervision Received:

General supervision is received weekly

Qualifications: Education Required:

Licensed Practical Nurse OR Licensed Vocational Nurse OR Registered Nurse
Associate or Bachelor?s degree in Nursing or completion of a Diploma Nursing School

Education Preferred:

BSN degree in Nursing

Experience Required:

2+ years of experience in a managed care healthcare setting
2+ years of Utilization Management (Helpful)
Experience with payer specific medical guidelines and how to apply them in an appeal
Experience using MCG and/or InterQual guidelines

Experience Preferred/Desirable:

Comprehensive knowledge of Medicaid and Medicare contractual provisions and NCQA accreditation requirements highly desirable.

Required Licensure, Certification or Conditions of Employment:

Current Unrestricted LPN, LVN, and/or RN license
Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

Detail oriented, excellent verbal and written communication and organizational skills.
Ability to work in both team and independent settings at all levels of the organization.
Exceptional customer service skills and experience working with diverse populations required.
Knowledge of health care terminology desirable.
Bi-lingual preferred.
Demonstrated ability in facilitating cross-functional teams.
Effective collaborative and proven process improvement skills.
Strong analytical and problem-solving skills.
Knowledge of analytics, metrics, and an ability to interpret data.
Excellent de-escalation and dispute resolution skills

Working Conditions and Physical Effort:

Regular and reliable attendance is an essential function of the position.
Fast paced office environment.
Work is normally performed in a typical interior/office work environment.
No or very limited physical effort required. No or very limited exposure to physical risk.
Occasional travel required

About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances

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