Appeals Nurse

Summary:

• Work Mode: Remote - FL
• Duration: 7 months with possibility to extend
• Schedule: M-F: 9am - 6pm EST (Possible weekends Saturdays - same as weekday schedule)

Responsibilities:

• Receive assignments electronically via company applications and excel sheets; emails are also sometimes used for case communication.
• Review appeal requests and medical records, and apply applicable medical necessity criteria.
• Write up the appeal clinical review and forward to MD for review and final determination.
• Receive the case back post MD review for clinical closure and route to coordinator for case closure.
• Handle 4-8 complete cases per day.
• Work remotely and self-directed to keep oneself at pace.
• Use clinical knowledge and experience to visualize the appeal request and understand the clinical picture.

Requirements:

• Required: Nursing certification/degree
• Required: RN or LPN FL Licensure
• At least 3 years in a clinical setting followed by at least 1 year experience in managed care/utilization management setting such as prior authorization clinical reviewer; appeals clinical reviewer preferred.
• Experience using InterQual criteria application.

Preferred Skills:

• Clinical utilization management experience – clinical reviews
• InterQual criteria application
• Able to work independently
• Experience in clinical mental health care is a plus.
• Preferred candidates that can work later shifts or weekends, once trained.
• Behavioral health background is a plus but not required.