100% remote Appeals Nurse (Oregon RN License required)

? 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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