[Hiring] Grievance and Appeals Nurse @Professional Management Enterprises

Role Description

Responsible for investigating and processing the most complex grievances and appeals requests from members and providers.

• Conducts investigations and reviews of member and provider medical necessity appeals.
• Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
• Extrapolates and summarizes medical information for medical director, consultants and other external review.
• Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
• Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
• Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
• Generates written correspondence to providers, members, and regulatory entities.
• Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

Qualifications

• Requires 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.
• Behavioral Health experience.
• Current active unrestricted RN license to practice as a health professional within the scope of licensure in IN.
• Requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• MCG (Milliman Care Guidelines) experience.
• CMCN (Certified Managed Care Nurse) certification strongly preferred.
• AS required/BS in Nursing preferred.

Requirements

• Must reside in Indiana, designated remote work position.
• Hours: Monday-Friday 8-5pm OR Tuesday - Saturday (Saturday's are half days) 4 (9HR shifts) 7am-5:00pm, 8am-6:00pm, 9am-7:00pm.
• Pay: $90,000; health, dental, and vision offered. 401k available. 80 hours of PTO and paid holidays.