Resolution Nurse

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Address intricate clinical complaints, grievances, and appeals.

• Examine documentation and interpret clinical-record data in accordance with clinical criteria and policies.

• Ensure adherence to regulatory and accreditation standards concerning member and provider matters.

• Facilitate clinical resolutions by coordinating with both internal and external clinician support.

• Document and summarize case outcomes for all parties involved.

• Provide advanced clinical support for corporate initiatives, departmental needs, and special projects.

• Compose recommendations and communicate solutions related to Complaints, Grievances, and Appeals.

• Identify, evaluate, and analyze complex clinical issues pertaining to corporate policies, procedures, and contracts.

• Consult with Management, Government Programs, group leaders, and other external stakeholders.

• Suggest enhancements, updates, and clarifications to existing policies and procedures.

• Monitor policy and procedure modifications and initiate updates to supporting documentation.

• Collaborate with departments on cases that necessitate legal guidance and recommendations.

• Act as a clinical reference for Plan personnel regarding inquiries and relevant guidelines.

• Conduct peer reviews and document findings as assigned.

• Provide audit support, desk mentoring, and functional training to colleagues.

• Offer rotating on-call weekend and holiday coverage.

⛳️ Requirements

• A Bachelor’s degree is mandatory.

• RN Certification is essential.

• A minimum of 5 years of clinical experience is required.

• Familiarity with Medicare C and D is necessary.

• Understanding of URAC and NCQA standards relevant to case management organizations.

• Knowledge of CMSA Standards of Practice concerning Complaints, Appeals, and Grievances.

• Insight into managed care principles and emerging health treatment modalities.

• Proficient in Microsoft Word, Access, Excel, Outlook, and clinical databases.

• Capability to operate a personal computer and perform talk-and-type documentation.

• Strong analytical, research, and organizational abilities.

• Excellent verbal and written communication skills.

• Project management capabilities with the ability to handle multiple assignments.

• Ability to work independently and adapt to shifting priorities.

• Willingness to provide rotating on-call weekend and holiday coverage.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Retirement Plan.

• Paid Time Off.

• Holidays.

• Volunteer time off.

• Incentive Plan.

• Tuition Reimbursement.

• Flexible work environment.

• Training and continuing education.

• Opportunities for professional and personal growth.

• Community volunteering opportunities.