As an Appeals and Grievances USRN, one must be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions as needed and ensure that quality of output and accuracy of information is maintained, in accordance to SLAs.

Investigate and process complex grievances and appeals requests from members and providers   Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review Document and logs appeal/grievance information on relevant tracking systems Generate written correspondence to providers, members, and regulatory entities Serve as a subject matter expert for appeals, grievances, and quality of care issues Utilize leadership skills Assist with or perform other relevant essential functions as required

Qualifications:

Unrestricted USRN mainland license Minimum of 2 years experience in utilization management / review Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience a plus but not required Excellent written, verbal communication, customer service and interpersonal skills. Working knowledge of current industry Able to effectively use Microsoft Office Suite PC applications Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service Knowledge of applicable accreditation standards, and local, state, and federal regulations Appeals and grievance experience required Strong problem-solving skills, facilitation skills, and analytical skills