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!
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.
MINIMUM EDUCATION REQUIREMENTS
SPECIAL KNOWLEDGE AND/OR SKILLS
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!