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Appeals Nurse RN

A Line Staffing Solutions

This is a Contract position in Plymouth, MA posted October 12, 2021.

Appeals Nurse RN openings with a major health insurance / managed care company based in the San Antonio, Texas 78251 area Starting ASAP Apply now with Luke H.

at A-Line Position is based out of San Antonio, TX – will be working from home, but is phased return to office hoping for Fall of 2021, still TBD Job Summary: Making outbound calls to members/providers/agencies to conduct a clinical investigation Creating a clinical appeal review to submit to Medical Directors Creating resolution letters with appeal decision Updating authorizations/Data entry Review of Evidence Packets for Fair Hearings Presenting Evidence to HHSC Fair Hearings Department on a Fair Hearing Call.

Performance expectations/metrics : Gradual increase in expectations – initially: 4 to 5 appeals per week Full production: 8 appeals per week on average, up to 12 weekly 6 months into the role – will be introduced to Fair Hearings Audit scores – 90% or above (measured monthly) Turnaround time – 30 days is standard, 100% compliance expected Pay: $40-$45 hourly (determined on experience) Shift: Mon-Fri 8am-5pm, possibility of overtime due to workloads.

(Currently not anticipated, but subject to change depending on volume) Required Skills: Registered Nurse with Appeals and Long Term Care experience.

Minimum 1 year of experience in Appeals/LTSS.

If no appeals experience, LTSS (Long-Term Services and Support) experience needed at least because it’s easier to teach appeals.

LTSS is more challenging to train 2 years clinical experience; previous health plan / Managed care organization experience would be great Associate’s Degree in Nursing Required.

Must be an active RN in Texas Proficient with Microsoft Office applications; Knowledge of InterQual criteria preferred.

Preferred Skills: Bilingual.

Member driven, call a lot of members and a lot are Spanish speaking.

BSN/Bachelor’s Degree highly preferred Why Apply: Full benefits available after 90 days: Medical, Dental, Vision, Life, Short-term Disability 401k after 1 year of employment: With employer match and profit sharing GREAT Hours Monday through Friday, 40 hours per week Competitive Pay Rate Keywords: Medical Coding, Concurrent Review, Denials, Grievance, Grievance and Appeals, Appeals and Denials, Utilization Review, Case Management, CCM, Case Manager, URAC, HEDIS, STARS, InterQual, CMS, Medicare, Medicaid, Utilization Management, Registered Nurse, Telephonic Nurse, PBM, Claims, Rx, Certified Case Manager, Care Coordination, Health Plan, Health Insurance, MCO, RN, Nurse, Managed Care, Medical Claims, Appeals, Mail Order Medications, Insurance Verification, Pharmacy, Prior Authorization, Patient Counselor, Healthcare, Medical Coding, Concurrent Review, Denials, Grievance, Grievance and Appeals, Appeals and Denials, Utilization Review, Case Management, CCM, Case Manager, URAC, HEDIS, STARS, InterQual, CMS, Medicare, Medicaid, Utilization Management, Registered Nurse, Telephonic Nurse, PBM, Claims, Rx, Certified Case Manager, Care Coordination, Health Plan, Health Insurance, MCO, RN, Nurse, Managed Care, Medical Claims, Appeals, Mail Order Medications, Insurance Verification, Pharmacy, Prior Authorization, Patient Counselor, Healthcare.

Job Requirements: Required Skills: Registered Nurse with Appeals and Long Term Care experience.

Minimum 1 year of experience in Appeals/LTSS.

If no appeals experience, LTSS (Long-Term Services and Support) experience needed at least because it’s easier to teach appeals.

LTSS is more challenging to train 2 years clinical experience; previous health plan / Managed care organization experience would be great Associate’s Degree in Nursing Required.

Must be an active RN in Texas Proficient with Microsoft Office applications; Knowledge of InterQual criteria preferred.

Preferred Skills: Bilingual.

Member driven, call a lot of members and a lot are Spanish speaking.

BSN/Bachelor’s Degree highly preferred Keywords: Medical Coding, Concurrent Review, Denials, Grievance, Grievance and Appeals, Appeals and Denials, Utilization Review, Case Management, CCM, Case Manager, URAC, HEDIS, STARS, InterQual, CMS, Medicare, Medicaid, Utilization Management, Registered Nurse, Telephonic Nurse, PBM, Claims, Rx, Certified Case Manager, Care Coordination, Health Plan, Health Insurance, MCO, RN, Nurse, Managed Care, Medical Claims, Appeals, Mail Order Medications, Insurance Verification, Pharmacy, Prior Authorization, Patient Counselor, Healthcare, Medical Coding, Concurrent Review, Denials, Grievance, Grievance and Appeals, Appeals and Denials, Utilization Review, Case Management, CCM, Case Manager, URAC, HEDIS, STARS, InterQual, CMS, Medicare, Medicaid, Utilization Management, Registered Nurse, Telephonic Nurse, PBM, Claims, Rx, Certified Case Manager, Care Coordination, Health Plan, Health Insurance, MCO, RN, Nurse, Managed Care, Medical Claims, Appeals, Mail Order Medications, Insurance Verification, Pharmacy, Prior Authorization, Patient Counselor, Healthcare.