VCN Nurse Jobs

Description

SHIFT: Day Job

SCHEDULE: Full-time

The Nurse Appeals is responsible for investigating and processing appeals requests from contracted providers. Primary duties may include, but are not limited to:

• Conducts investigations and reviews contracted provider appeals.

• Reviews medical records of denied services for medical necessity.

• Extrapolates and summarizes medical information for medical director.

• Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval, when applicable.

• Ensures that appeals are resolved timely to meet regulatory timeframes.

• Documents and logs appeal information on relevant tracking systems and mainframe systems.

• Generates written correspondence to contracted providers.

• Utilize leadership skills and serves as a subject matter expert for appeals issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

Qualifications

Qualifications - Internal

• Requires 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.

• Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.

• AS/BS in Nursing preferred.

• For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

• Requires experience with MS Office products.

• Prefer experience researching Medicare clinical guidelines: NCD, LCD, Medicare Benefit Policy, etc.

• Prefer experience reviewing claims and researching CPT codes or ICD-9 codes.

• UM experience highly desirable

• Good computer and typing skills.

REQNUMBER: PS41299-Virginia