Nurse Appeals (US)

Nurse Appeals role overseeing investigations and processing of medical necessity appeals from members and providers. Conducts reviews of prospective, inpatient, or retrospective medical records to determine medical necessity, extrapolates and summarizes clinical information for medical directors and consultants, prepares recommendations to uphold or deny appeals, and ensures timely resolution of appeals and grievances within regulatory timeframes. Documents activities in tracking/mainframe systems, generates written communications to providers and members, and serves as a SME for appeals/grievances/quality of care while guiding clinical and non-clinical team members toward expedited issue resolution. Requires HS diploma or equivalent, RN licensure, and experience in managed care; AS/BS in Nursing preferred; strong preference for Medicare guidelines familiarity and experience with claims coding and healthcare software. Vaccination may be required per policy; hybrid/virtual work model with some onsite requirements; location flexibility within listed hubs; postings indicate multiple US locations and a centralized hybrid approach.