Appeals And Grievances Registered Nurse

Overview

• Investigate and respond to clinical appeals and grievances submitted by members and providers.
• Ensure compliance with CMS and DOH regulations in appeals processing.
• Conduct clinical reviews of appeals regarding organizational determinations and payment denials.
• Prepare cases for external appeal processes, including Fair Hearings and IRE reviews.
• Document all relevant information in the appeals determination process accurately and timely.
• Collaborate with various departments to ensure effective resolution of appeals and grievances.
• Track compliance with requested actions and analyze data for timely determinations.
• Represent the organization at NYS Fair Hearings, preparing and presenting cases effectively.
• Utilize advanced clinical knowledge to perform thorough investigations and assessments.

Key Responsibilities & Duties

• Investigate appeals and grievances, ensuring adherence to regulatory requirements.
• Conduct clinical reviews for medical necessity and quality of care assessments.
• Prepare detailed case narratives and summaries for appeal processes.
• Coordinate with internal departments to gather necessary documentation for cases.
• Generate acknowledgment letters and follow up on additional information requests.
• Track and analyze clinical decisions to identify improvement opportunities.
• Present cases to medical directors and external reviewers effectively.
• Ensure timely submission and tracking of correspondence for appeal cases.
• Attend and represent the organization at Fair Hearings, preparing cases thoroughly.

Job Requirements

• Bachelor of Science in Nursing (BSN) required.
• Minimum of 2 years of managed care or hospital-based utilization/case management experience.
• Knowledge of appeals and grievances processes and regulations.
• Strong customer service skills and ability to collaborate effectively.
• Proficiency in documentation and case preparation for appeal processes.
• Experience with CMS and DOH regulatory compliance preferred.
• Advanced clinical knowledge and communication skills.
• Ability to analyze and interpret data for timely determinations.
• Entry-level position requiring strong organizational and investigative skills.