We're working on behalf of a health benefits provider that provides health coverage to more than 40 million members in the US. through a number of subsidiaries. One of the nation’s largest health insurers, the company's plans include PPO, HMO, POS, indemnity, and hybrid plans offered to employers, individuals, and Medicare and Medicaid recipients. The company boasts one of the largest and most successful Medicaid businesses in the nation. That business is also the fastest growing sector within the company. Their commitment and focus on government health programs is the foundation upon which they are creating better care for their members, greater value for their customers, and better health for our communities.
Looking for a great opportunity with a leader? We seek a Registered Nurse with two (2) or more years of appeals experience in a managed care setting for the role of Medicaid RN - Nurse Appeals Senior. In this role you will be responsible for investigating and processing the most complex grievances and appeals requests from members and providers. You will conduct investigations and reviews of member and provider grievances and appeals. You will review prospective, inpatient, or retrospective medical records of denied services for medical necessity. You will extrapolate and summarize medical information for medical director, consultants and other external review. You will prepare recommendations to either uphold or deny appeal and forwards to Medical Director for approval. You will ensure that appeals and grievances are resolved timely to meet regulatory timeframes. You will document and logs appeal/grievance information on relevant tracking systems and mainframe systems. You will generate appropriate written correspondence to providers, members, and regulatory entities. You will serve as technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.
Candidates must be a graduate of an accredited school of nursing and be licensed as an RN in the state of Minnesota. BSN is preferred. Must have two (2) - four (4) years or more of experience in a managed care healthcare setting. Appeals experience highly desired. Utilization Management experience highly desired. Medicaid experience preferred. Critical Care (ER/ICU) experience very helpful. Five (5) or more years of direct-care experience strongly preferred.
Competitive compensation and excellent benefits. This is a terrific opportunity to join a highly successful organization where the skills and passions of thousands come together, creating an impressive force with the power to change lives and the future of health care. For more information call 941.739.1400 or submit your resume now by clicking on the button below that says "Apply Now."
Edge Recruitment Solutions
888.666.2450 or 941.739.1400