Appeals Nurse - Wilmington - Alliance

    Alliance
    Alliance Wilmington

    1 week ago

    Employment $66,227 - $92,407 (USD) per year
    Description

    Appeals Nurse

    The Appeals Nurse serves as a clinical resource for the Appeals Team ensuring timely customer-focused responses to pharmacy and physical health appeals.

    • Triage member appeals: gathering documentation and interpreting information submitted in preparation for assignment of PH appeals to appropriate medical reviewer.
    • Analyze trends within appeals functions creating actionable analysis identifying effective solutions under minimal supervision.

    This position requires strong analytical skills utilizing data analysis techniques integrating programmatic information into required data sets for interpretation.
    We are seeking a qualified Registered Nurse who can assist in resolving member complaints related to Adverse Benefit Determinations enforcing compliance with state regulations tailoring our plan contract standards while acting as settlement authority during mediations at Office of Administrative Hearings (OAH). Strong communication skills verbal written graphic presentation essential interacting internal external stakeholders addressing quality assurance issues promptly reviewing regulatory timeframes accuracy appeal cases monthly peer reviews improving processes maintaining current guidelines requirements
    Duties will also involve preparing presenting complex case summaries Medical Directors managing general functions identification strategies improvement practices enhancing team workflow efficiency proactive problem solving generating innovative practical recommendations supporting company-wide initiatives,
    Leverage expertise knowledge healthcare environment assisting colleagues staff analyzing policies procedures revision editing according agency rules steps advocacy management statutory international environments.


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