RN Appeals Coordinator

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

📋 Description

• Evaluate appeal cases pertaining to diagnosis codes and medical necessity.

• Deliver thorough responses in alignment with medical practice standards, corporate medical policies, code review logic, contractual guidelines, and regulatory requirements.

• Collaborate with medical departments on legal matters concerning benefits.

• Clarify the application of medical coverage policies.

• Address inquiries from the Arkansas Insurance Department and other state insurance departments regarding complaints and appeals within legally mandated timelines.

• Practice nursing within the boundaries of licensure.

• Make decisions based on evidence to ensure compliance, appropriate care levels, and patient safety.

• Stay updated on medical and surgical procedures, products, healthcare services, pharmaceuticals, healthcare delivery trends, organizational procedures, policies, and contracts.

• Undertake additional duties as assigned.

• Report to Senior Counsel.

⛳️ Requirements

• Preferred Bachelor's degree in Nursing.

• Required Registered Nurse (RN) with an active state license in good standing in the relevant state(s) where job responsibilities are carried out.

• At least five (5) years of clinical nursing experience, encompassing a diverse background in various nursing aspects.

• Minimum of two (2) years' experience in utilization review, medical policy, and/or case management is required.

• Familiarity with HCPCS/CPT/Revenue codes and fundamental coding principles.

• Understanding of claims processing rules and logic.

• Knowledge of Health Plan operations, regulatory agencies, and State/Federal regulations related to healthcare.

• Prior experience in the appeals and/or grievances process is preferred.

• Exceptional oral and written communication skills.

• Detail-oriented and meticulous.

• Strong analytical, critical thinking, organizational, and time management capabilities.

• Proficient in Microsoft Office, including Word, Excel, Outlook, and PowerPoint; adept at navigating multiple systems and keyboarding.

• Ability to exercise sound judgment and decision-making based on facts and established guidelines.

• Capability to foster collaborative relationships.

• Ability to work autonomously with minimal supervision.

• Competence in interpreting complex documentation.

• Must ensure the security and confidentiality of records and information.

• Must adhere to segregation of duties guidelines.

• Must practice nursing within the limits of licensure and comply with applicable regulations and standards.

🏝️ Benefits

• Remote work arrangement available.

• Regular employment status.

• Occasional campus travel within walking distance of the primary work location.

• Flexibility to work remotely or in an office environment.