• RN, Appeal Nurse

    Job Locations US-VA-Glen Allen
    Job ID
    2018-5045
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
     
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
     
    If this sounds like you, read on!

    Overview

    The Appeal Nurse’s will manage member and practitioner appeal activities, to ensure that service standards are met, and operations are consistent with the health plan policies, as well as the policies of the regulatory agencies. The incumbent will participate in managing the organization’s State Fair Hearing review for our Medicaid population, including handling expedited and standard requests and providing oversight of program resolution and assist in processing of the cases.  Ensures State Fair Hearing requests are processed in accordance with regulations, compliance standards and policy and procedures.  Investigation and preparation of case summaries and resolution statements based on clinical information, benefits, applicable regulations related to member dispute of decisions.  The Appeal Nurse shall also be responsible for serving as the plan’s subject matter expert and liaison for the members and practitioners related to all appeals activities.  The incumbent is also responsible for creating monthly, quarterly and annual reports pursuant to the Department of Medical Assistance Services (DMAS), National Committee for Quality Assurance (NCQA), regulatory requirements and agencies.  

    Responsibilities

    • Responds to member and practitioner appeals with minimal direction
    • Investigates and resolves member and practitioner appeals within plan regulatory and accreditation timeframes
    • Prepares, attends and presents appeals documentation for plan, regulatory hearings and/or during audits
    • Prepares appeals written documentation responses
    • Provides timely assistance to members and practitioners in filing formal appeals and ensures that members are advised of their appeal rights
    • Works collaboratively, coordinates, communicates and integrates recommendations from impacted organizational departments and/or Senior Level Executives and other designated staff, as approved and required
    • Generates reports with trend analysis and recommendations for quality improvement
    • Communicates detailed account of risk management issues to the Manager within the specified timeframe
    • Assists with training, in-services and quality audits as a result of plan, regulatory or accreditation requirements
    • Acts as an appeal Subject Matter Expert (SME) in the absence of the Medicare or Medicaid Grievances & Appeals managers
    • Attends Member Advisory Committee (MAC) and Provider Advisory Committee (PAC) meetings

    Qualifications

    MINIMUM EDUCATION REQUIREMENTS

    • Current, active, unrestricted nursing license

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Strong interpersonal skills
    • Exceptional interpersonal and problem solving skills
    • Appeals processes.
    • Positive and approachable demeanor
    • Strong written and oral communication skills
    • Proficient in MS Office applications (Word, Excel, Power Point)

    WORK BACKGROUND/EXPERIENCE

    • Customer service experience in a health care office environment
    • Ability to succinctly deliver pertinent information to a variety of audiences to include members, practitioners, organizational executives, attorneys and/or accreditation and regulatory auditors
    • Working knowledge of computers and word processing programs
    • Experience working with low income, indigent and/or disadvantaged populations

    PHYSICAL REQUIREMENTS

    • Requires extensive sitting with periodic standing and walking.
    • Requires significant use of personal computer, phone and general office equipment.
    • Needs adequate visual acuity, ability to grasp and handle objects.
    • Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
    • May require off-site travel

     

    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

     

    Our mission is to inspire healthy living within the communities we serve!

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