A&G USRN

• Investigate and process complex grievances and appeals requests from members and providers
• Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity
• Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards
• Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review
• Document and logs appeal/grievance information on relevant tracking systems
• Generate written correspondence to providers, members, and regulatory entities
• Serve as a subject matter expert for appeals, grievances, and quality of care issues
• Utilize leadership skills
• Assist with or perform other relevant essential functions as required

Qualifications:

• Unrestricted USRN mainland license
• At least 2 years experience in utilization management / review
• Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience an advantage
• Excellent written and verbal communication skills.
• Excellent customer service and interpersonal skills.
• Working knowledge of current industry Microsoft Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management
• Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service
• Knowledge of applicable accreditation standards, and local, state, and federal regulations
• Appeals and grievance experience required.
• Strong problem-solving skills, facilitation skills, and analytical skills.
• Flexible to work in globally distributed teams and on business need support weekend transactions