TITLE: UM/Appeals RN

LOCATION: Hybrid; New Hyde Park, NY 11042 (preference is for someone to be local to NY and able to come into the office)

Looking for 5 RNs to do appeals work under the team handling on average 10 cases a day. These will be a mix between simple and complex cases. They will be reviewing documentation, codes, and more for out of Network bills and cost and making determinations on how to move forward based on the evidence.

***Must have strong UM or Appeals background NY RN license***

GENERAL RESPONSIBILITIES:

This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical level review, Prior Authorization and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

DUTIES:

1. Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements, complete electronic worksheets and preparing final determinations.

2. Act as a resource for the administrative and clinical staff in training, problem solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles.

3. Participate in collaborative training.

QUALIFICATIONS:

1. Licensed as a Registered Professional Nurse in New York State.

2. Knowledge and experience with electronic medical records, UM and Appeals

3. Ability to oversee, problem solve and work collaboratively with peers, medical, analytical, and administrative support staff.

EDUCATION & EXPERIENCE:

1. Baccalaureate degree in Nursing or graduate of an approved Registered Professional Nurses training program and licensed to practice in the State of New York.