This nurse reviews denied claims and clinical documentation to determine whether appeals should be overturned, upheld, or escalated for Medical Director review. The work centers on applying organizational policies and NCQA guidelines to ensure timely, accurate, and compliant appeals resolution for members and providers. It is a computer-based role that includes case preparation, documentation, and coordination with internal teams and external providers.
Key Responsibilities
- Review clinical information and denied claims to determine appropriate appeal outcomes.
- Prepare cases for Medical Director review when clinical criteria are not met.
- Generate compliant appeal resolution letters for members and providers.
- Create authorization events for overturned denials and maintain accurate system documentation.
- Request additional clinical information from providers to support appeal review.
- Gather case materials for Administrative Law Hearings.
- Track appeals within required NCQA turnaround timeframes and databases.
- Assist with policy updates and revisions to support NCQA and contractual requirements.
Required
- Active Licensed Practical Nurse (LPN) license in good standing with at least 3 years of clinical nursing experience, or active Registered Nurse (RN) license in good standing with at least 2 years of clinical nursing experience.
- For designated positions, active New York State RN licensure is required.
- Ability to interpret and apply clinical and claims information using organizational policies and NCQA guidelines.
- Proficiency with Microsoft Office applications, including word processing, spreadsheets, and email.
- Strong written communication, organizational, and clinical judgment skills.
Preferred
- Experience with utilization review or appeals review.
- Knowledge of InterQual criteria.
- Familiarity with regulatory and accreditation standards related to NCQA.
- Experience preparing materials for Administrative Law Hearings.
- Experience collaborating with Medical Directors and other clinical and non-clinical stakeholders.
Benefits & Perks
- Fully remote work.
- Contract position.
- Hourly pay range of $33.00 to $38.00.
- Medical, dental, and vision coverage, if eligible.
- 401(k) retirement plan with pre-tax and Roth post-tax contributions, if eligible.
- Life insurance, short- and long-term disability, and health spending account, if eligible.
- Transportation benefits and employee assistance program, if eligible.
- PTO, vacation, or sick leave, if eligible.