Appeals Nurse (Full time Remote, North Carolina Based)

The Appeals Nurse is responsible for triaging member appeals related to Adverse Benefit Determinations of Physical Health and Pharmacy service requests (including determining if the appeal should be processed as expedited or within the standard resolution timeframes). The Appeals Nurse ensures clinical information related to appeals is directed to the appropriate physician to be reviewed based on medical necessity. The Appeals Nurse serves as a clinical resource for the Appeals Team is also responsible for analyzing and resolving member appeals in compliance with state regulations and Alliance’s Tailored Plan contract. The Appeals Nurse will also represent Alliance Health as the settlement authority during OAH Mediations.

This position is full-time remote opportunity. The selected candidate must reside in North Carolina.

Responsibilities & Duties

Triage Member Appeals

• Triage and prioritizes cases and other assigned duties to meet required turnaround times
• Gather, review, interpret and summarize documentation and additional information submitted in preparation for assignment of PH appeals to appropriate medical reviewer
• Prepare and present cases to Medical Directors for timely and accurate decisions

Provide Clinical Support to Appeals Team

• Utilize clinical knowledge of administrative codes, laws, statutes and Tailored Plan administrative regulations to assist in the development and the revision of policies and procedures related to the appeals process
• Provide support and oversight of the appeals process as it pertains to clinical criteria
• Identify potential quality of care issues, service or treatment delays and intervene as clinically appropriate
• Assist non-clinical staff in interpreting clinical documentation when applicable

Management of General Functions

• Ensure timely, customer-focused responses to pharmacy and physical health appeals, identify trends and emerging issues, report and recommend solutions
• Leverage critical thinking to identify trends within appeals and other functions
• Create actionable analysis and identify the most effective party to address any identified issues with minimal supervision
• Work independently to mediate complex relationships between multiple external and internal stakeholders so that all parties are satisfied with identified resolutions
• Utilize professional communication skills to provide information to internal and external stakeholders verbally and in writing
• Monitor timelines to ensure that quality assurance issues and reports are reviewed in a timely manner as to be most effective for agency processes
• Use analytical skills to define recommendations and improve practices

Management of Appeals (Pharmacy and Physical Health Appeals)