Job Description:
Clinical Appeals Nurse
BC Forward is currently seeking a highly motivated : Clinical Appeals Nurse in Remote
Position Title: Clinical Appeals Nurse
Location: Remote
Anticipated Start Date: 12/16/2024
(Please note this is the target date and is subject to change. BCforward will send official notice ahead of a confirmed start date.)
Expected Duration: 01 Year Contract
Job Type: Full Time 40 Hours Contract
Pay Range: $30/hr-$32/hr on W2
(Please note that actual compensation may vary within this range due to factors such as location, experience, and job responsibilities, and does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).
Job Summary:
The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.
Qualifications:
- Education and Experience:
- RN License required
- Associates Degree or equivalent years of relevant experience required
- Managed care, appeals, and Medicaid experience preferred
- Utilization review experience is strongly preferred
Competencies, Knowledge and Skills:
- Intermediate proficiency with Microsoft Office products and Facets
- Knowledge of NCQA, URAC, OAC, and MDCH regulations
- Strong written and oral communication skills
- Ability to work independently and within a team environment
- Critical listening and thinking skills
- Proper grammar usage
- Time management skills
- Proper phone etiquette
- Customer Service oriented
- Decision making/problem solving skills
- Familiarity of healthcare field
- Knowledge of Medicaid
- Flexibility
- Change resiliency
Licensure and Certification:
- Current, unrestricted license as a Registered Nurse (RN) is required
- MCG Certification is required or must be obtained within six (6) months of hire
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Duties and Responsibilities:
- Responsible for the completion of clinical appeals and state hearings from all states
- Review and complete all provider clinical appeals within required timeframes Review and complete member clinical appeals within required timeframes
- Review all information necessary to prepare State Hearing packets
- Communicate with state agencies and internal departments to prepare for State Hearings
- Attend assigned State Hearing and complete all required compliances
- Complete required compliances for Administrative Hearing decisions
- Apply Client Medical Policy and Milliman guidelines when processing clinical appeals
- Issue notification letters to providers and members
- Issue administrative denials appropriately
- Refer denials based on medical necessity to medical director
- Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates
- Conduct monthly, quarterly, and ad hoc appeals reporting
- Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Review
- Ensure compliance with regulatory and accrediting requirements
- Perform any other job duties as requested
Benefits:
BCforward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
About BCforward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.
BCforward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.
Interested candidates please send resume in Word format Please reference job code 231508 when responding to this ad.
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Job Snapshot
Employee Type
Contractor
Location
Dayton, OH (Onsite)
Job Type
Admin - Clerical, Biotech
Experience
Not Specified
Date Posted
11/15/2024
