Overview:   

In this role you should independently be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained, in alignment with SLAs. 

RESPONSIBILITIES/TASKS:

• Investigate and process complex grievances and appeals requests from members and providers
• Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity 
• Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards
• Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review
• Document and logs appeal/grievance information on relevant tracking systems
• Generate written correspondence to providers, members, and regulatory entities
• Serve as a subject matter expert for appeals, grievances, and quality of care issues
• Utilize leadership skills 
• Assist with or perform other relevant essential functions as required 

This position description identifies the responsibilities and tasks typically associated with the performance of the position.  Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION:

Bachelor’s degree in nursing, allied health, business, or related field preferred. Registered Nurse with current unrestricted Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment. 

EXPERIENCE:

Minimum two (2) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.  Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. One (1) year health insurance plan experience or managed care environment preferred.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Unrestricted USRN mainland license 
• At least 2 years experience in utilization management / review
• Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience an advantage 
• Excellent written and verbal communication skills. 
• Excellent customer service and interpersonal skills.
• Working knowledge of current industry Microsoft Office Suite PC applications. 
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management
• Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service
• Knowledge of applicable accreditation standards, and local, state, and federal regulations 
• Appeals and grievance experience required. 
• Strong problem-solving skills, facilitation skills, and analytical skills. 

Geographic Responsibility:  Remote, US

Type of Employment: Full-time, permanent 

FLSA Classification (USA Only): Exempt 

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:  

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.  

• Work across multiple time zones in a hybrid or remote work environment. 

• Long periods of time sitting and/or standing in front of a computer using video technology. 

• May require travel dependent on company needs. 

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990.  Candidates may be required to go through a pre-employment criminal background check. 

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. 

#LI-Remote 

**The annual US base salary range for this position is $50/hr. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.