Appeals Nurse - 240421 New

Job Title: Appeals RN

Experience: Appeals experience not required. Open to various clinical backgrounds/experience. Must have 2+ years of clinical experience post graduation, must has critical thinking and problem solving skills.

***Must have BSN and NYS RN license***

Location: Onsite required; office in Lake Success/New Hyde Park, NY

Hours of Operation: M-F 7a-5:30p *flexible start between 7am-9am (40hrs/wk)

Start date: ASAP

Pay: $50-54/hr *DOE

Volume: Will do appeals work under the IDR team handling on average 10 cases a day. These will be a mix between simple and complex cases. They will be reviewing documentation, codes, and more for out of Network bills and cost and making determinations on how to move forward based on the evidence.

This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical level review, Prior Authorization, and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

DUTIES:

1. Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements, complete electronic worksheets and preparing final determinations.
2. Act as a resource for the administrative and clinical staff in training, problem solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles.
3. Training and mentoring new RNs as the project expands.
4. Claims assessment and adjudication.
5. Participate in collaborative training.
6. Other activities as may be deemed necessary.

QUALIFICATIONS:

1. Knowledge and experience with electronic medical records.
2. Ability to oversee, problem solve, and work collaboratively with peers, medical, analytical, and administrative support staff.
3. Excellent written and verbal skills.
4. Ability to work independently with little supervision.
5. Ability and desire to be flexible, innovative, and creative.

EDUCATION AND EXPERIENCE:

1. Licensed, Registered Nurse, required in New York
2. Baccalaureate degree in Nursing
3. Minimum of two years’ experience in a clinical setting, required.