100% remote Appeals Nurse (Oregon RN License required)

• Research and Investigate member and/or provider appeals and grievance requests, includes review of UM/claim denial reasons, contract/regulatory rules, benefits and documentation received on appeal/grievance. • Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance. Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions. • Prepares case file (original denial, all information received on appeal, medical records, etc.). • Schedule participant/member for committee panel sends scheduling letter if needed. • Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings. • Prepare and send case files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.). • Communicates updates and status of outstanding member and provider complaints/issues to management. • Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures. • Update and/or generate authorization updates requests, for services that have been appealed. • Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue. • Maintains quality and compliance standards as dictated by the state and federal entities • Maintains contractual agreements with participating providers related to appeals and grievances. • Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk. • Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management. • Obtain authorization for release of sensitive and confidential information. • Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances. • Ensure case file is sent to the appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates. • Provide support presenting cases and facilitating committee meetings as needed. • Send appeal to an independent review organization portal, for those appeals that require an external match specialty review. • Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, • Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed. • Creates a decision letter with detailed description of the nature of appeal / grievance including rationale for the decision and options for moving forward. • Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances. • All other duties as assigned Job Types: Part-time, Contract Pay: $40.00 per hour Expected hours: 20 – 32 per week Medical Specialty: • Medical-Surgical Physical Setting: • Acute care Experience: • Appeals and Grievances experience on the payor side: 2 years (Required) License/Certification: • RN License in Oregon (Required) Work Location: Remote Apply Job!