Appeals Medical Reviewer

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.

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.
Requirements: Expertise Nursing Job Type Full-Time Regular Location IL - Chicago, TX - Richardson


Back to top