Appeals Nurse

Location: Virginia Beach, VA
Date Posted: 02-01-2019
Appeals Nurse (RN or LPN)
Virginia Beach, VA 
*** This is a Full-Time, Benefits Available, CONTRACT opportunity, expected to last 3 months, or longer! ***

Appeals Nurse Job Summary: 
  • Supports the organization by working to resolve provider payment disputes through advanced and complicated utilization review of the appropriateness of medical care requiring considerable clinical judgment, independent analysis, and detailed knowledge of managed care and organizational guidelines.   
  • Manages the consolidation of the complaints and grievance activities on a quarterly basis, and prepares monthly, quarterly and annual reports on assigned quality improvement activities.
  • Maintains strict compliance with federal, state and NCQA requirements and guidelines
Appeals Nurse Background: 
  • Current, valid, and unrestricted state Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.) license.
  • Minimum of 2 years acute care clinical nursing experience
  • Minimum of 2 years of previous experience in Utilization Review and/or Denials & Grievances & Appeals in a Managed Care Organization.
  • Minimum of 1-2 years of recent experience at a health plan or other Managed Care Organization (HMO/TPA/IPA/etc).
  • Experience using standardized clinical guidelines (InterQual or Milliman) is required. 
  • Must be able to differentiate between PCP rendered care and specialty care; and be able to identify clinical quality of care issues.
  • Understand Utilization Review guidelines, Medicare and Medicaid regulations, and appropriate state plan requirements.  
410.885.4745 (CALL – TEXT – FAX)

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