Appeals Nurse - HGB SCA Remote LA
The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Appeals Nurse 2 reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Coordinates the clinical resolution with internal/external clinician support as required. Documents and summarizes to all parties involved in the case the investigation's results. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
KEY ACCOUNTABILITIES
Review medical documentation, obtain additional information that may be needed including timeframes when physician is available for peer to peer review, and forward to physician review companies or TQMC. Monitor and follow up for timeliness and review response and determination to insure follows TRICARE policy requirements. If discrepancies found will send back for follow up review and correction as needed.
Review, coordinate, arrange and maintain Second level Review /Reconsideration records and patient and provider response letters
Provide education to beneficiaries and providers regarding second level review time frames, process and review determinations. If needed provide education on alternatives for services that may be not be approved
Maintain knowledge of TRICARE, all HGB policies and procedures as well as medical necessity review criteria and privacy requirements
Use your skills to make an impact
Required Qualifications
Our Department of Defense contract requires U.S. Citizenship
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Countries Benefits/Perks401(k) retirement savings plan Bonus incentive plan Competitive benefits Dental Life Insurance Medical Paid parental and caregiver leave Paid Time Off Parental and Caregiver Leave Personal holidays Time off Vision Vision Benefits Volunteer time Volunteer time off
SkillsBI Business Clinical nursing Data Documentation Excel Healthcare HIPAA Investigation Leadership Medicaid Medicare Microsoft Office Organizational Outlook Quality Management Security Strategy Utilization Review Wellness
Tasks- Documentation
- Training
3 years
EducationAssociates Bachelor's Bachelor's degree Business DO
Certifications RestrictionsU.S. citizenship required Work from a dedicated space Work from a dedicated space lacking ongoing interruptions
Timezones