Appeals Medical Reviewer

Job ID: DLP-1019017 Description:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can email us here to request reasonable accommodations.

Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "my account" and click on "View your job submissions".

BASIC FUNCTION:

This position is responsible for coordinating appeals for all lines of business; reporting, monitoring, scheduling and facilitating appeals according to various regulatory requirements; requirements include, Department of Insurance, DOL-ERISA and Accreditation standards; analyzes appeals data according to the corporate quality improvement performance data; and identifies areas of improvement as they relate to initial denials and appeals.

JOB REQUIREMENTS:

  • Registered Nurse (RN) with current unrestricted license in good standing in state of operations.
  • 5 years clinical experience to include implementing or administering managed care or quality assurance activities.
  • Experience in Utilization Management or audit.
  • Ability to work alone in a fast paced, demanding environment and impacting members.
  • Knowledge and understanding of associated state and federal guidelines and regulation.
  • Written and verbal communication skills and facilitating skills.
  • Ability to set own goals and monitor work flow with minimal supervision.
  • Ability to deal with internal and external customers, including representative of DOI in a rapport-developing manner.
  • Organizational skills.
  • Detail oriented.

PREFERRED JOB REQUIREMENTS:

  • BSN, BS/BA, or Bachelor Degree.
  • Knowledge of grievance and appeal processing.
  • Bilingual in English and Spanish.

Requirements: Expertise Nursing, Other Job Type Full-Time Regular Location NM - Albuquerque


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