100% remote Appeals Nurse (Health plan experience required) CA RN...
Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department.
Investigation, and resolution of clinical member complaints (grievances/appeals) utilizing all regulatory requirements. Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identification of Expedited Cases and resolution within 72 hours.
Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.
Investigation and preparation of State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review... organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE).
Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.
Perform other duties as assigned.
Job Types: Full-time, Contract
Pay: $40.00 per hour
Expected hours: 40 per week
Standard shift:
? Day shift
Supplemental schedule:
? Holidays
Weekly schedule:
? 5x8
? Every weekend
Experience:
? Health insurance: 2 years (Required)
? Medicare: 2 years (Required)
? Appeals: 2 years (Required)
? Quality of Care: 2 years (Required)
License/Certification:
? California RN License (Required)
Work Location: Remote
Similar Remote Jobs
100% remote Appeals Nurse (Health plan experience required) CA RN...
Posted on: 22-07-2024 03:03
Remote Apple Data Entry ( Work from home )
Posted on: 22-07-2024 03:03
Data Entry Specialist (Typist) - Remote | WFH
Posted on: 22-07-2024 03:03
Apple Remote jobs ? Entry Level
Posted on: 22-07-2024 03:03
Needed - Data Entry Operator (Remote Work)
Posted on: 22-07-2024 03:03
Part-Time Delta Airlines Data Entry Remote Jobs: Earn $25/Hour ? US
Posted on: 22-07-2024 03:03
Senior Software Engineer, Profile (Bank Tech) (Remote)
Posted on: 22-07-2024 03:03
(Work From Home Jobs) Apple Data Entry Jobs ? Entry level
Posted on: 22-07-2024 03:03
DATA ENTRY CLERK
Posted on: 22-07-2024 03:03
Remote Customer Service Representative
Posted on: 22-07-2024 03:03
(Entry level Remote jobs) American Express Data Entry Jobs
Posted on: 24-01-2025 04:51
Director Cybersecurity PAM and Monitoring
Posted on: 04-11-2024 05:37
Data Entry Specialist (Remote)
Posted on: 28-08-2024 00:00
Legal/Judicial Transcriptionist Independent Contractor (Remote)
Posted on: 14-08-2024 00:00
Remote Administrative Support Specialist/ Customer Service
Posted on: 23-10-2024 04:42
Amazon ? User Experience (UX) Researcher Intern ? 2023 (US) ? Seattle, WA
Posted on: 06-11-2024 04:55
Processing Support - Data Entry - Hybrid remote (2 days in the office)
Posted on: 23-02-2025 00:00
Part Time Healthcare Claims Denials Specialist
Posted on: 28-08-2024 00:00
FinOps Analyst - AP, FinOps Digital AP
Posted on: 13-09-2024 00:00
Caregiver/CNA - 8, 10 and 12 Hour Overnight Shifts! Weekly Pay!
Posted on: 16-01-2025 19:17