Lead Utilization Management Specialist – Appeals

This is a fully remote position, open to applicants in South Dakota, +1 more state.

📋 Description

• Acts as the subject matter expert on appeals and denials.

• Provides leadership, oversees cases, coordinates workflows, and ensures quality assurance throughout the appeals process.

• Creates initiatives for process improvement and problem-solving.

• Collaborates with various departments.

• Aids the supervisor in monitoring quality assurance and accreditation.

• Conducts reviews of clinical-based denials within specified timeframes.

• Guarantees adherence to current governmental and industry audit practices and requirements.

• Mentors colleagues in their technical areas and shares expertise on critical matters.

⛳️ Requirements

• Bachelor's degree in nursing is preferred.

• Graduation from a nationally accredited nursing program is required.

• A minimum of three years of related experience is required.

• Currently possesses an unencumbered registered nurse (RN) license from the State Board of Nursing.

• Certification as a Professional in Healthcare Quality is preferred.

🏝️ Benefits

• Fully Remote.

• Monday - Friday.

• 8am-5pm.