Appeals Review Nurse

This position is available fully remote in Washington State.

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work. 
• Reduce health disparities. 
• Become an anti-racist organization. 
• Create an equitable work environment. 

About the Role

The Appeals Review Nurse is responsible for performing clinical review on all appeals cases requiring a Medical Necessity Determination. They will perform assessments and medical necessity reviews for appeal requests using utilization review criteria, technologies, and tools. Supporting physician decision-making, working collaboratively with all members of the health team both internal and external to the organization. Ensuring timely processing of appeals cases which meets CMS, NCQA, and Medicaid guidelines for appeals processing.

To be successful in this role, you:

• Have a current, unrestricted RN or LPN Multistate or Washington State license, required.
• Are an LPN with 3+ years of clinical experience or RN with 2+ years of clinical nursing experience, required.
• Have previous experience with Utilization Management or Appeals, preferred.

Essential functions and Roles and Responsibilities:

• Review clinical information for all appeals against appropriate criteria to determine medical necessity of the services requested.
• Request additional information, as appropriate from provider(s) to facilitate timely appeal resolution.
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received.
• Gather and prepare case information for Administrative Law Hearings.
• Participates and leads process improvement initiatives focused on improving upstream appeals processes.
• Provides summary feedback to Utilization Management department for process improvement opportunities.
• Assists in reviewing UM authorization requests for medical necessity.
• Delivers timely written notification to patient or family members and communicates with members of the health care team.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.
• Reporting to work on time and for all scheduled shifts is essential to this position.

Knowledge, Skills, and Abilities:

• Knowledge of regulatory and certification requirements and their impact on the organization (for example, HEDIS, CAHPS, and NCQA).
• Ability to effectively manage and maintain quality standards for a high volume of appeals reviews.
• Demonstrated proficiency and experience applying medical necessity criteria in reviewing authorization and appeals requests.
• Demonstrated proficiency and experience with Microsoft office products.
• Effective written and verbal communication skills; able to communicate with and collaborate effectively with physician and allied health care providers orally and written.
• Ability to work independently.
• Ability to multi-task and deal with complex assignments on a frequent basis.
• Ability to work in matrix environment with guidance from both direct supervisor as well as clinical and operational leaders across the organization.
• Demonstrate professional courtesy to others and maintain confidentiality.
• Experience in care management workflow systems.
• Demonstrated organizational, time management, and project management skills.

Note: If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Non-Exempt and is eligible for overtime and has a 10% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.

CHPW offers the following benefits for Full and Part-time employees and their dependents: 

•  Medical, Prescription, Dental, and Vision
•  Telehealth app
•  Flexible Spending Accounts, Health Savings Accounts
•  Basic Life AD&D, Short and Long-Term Disability
•  Voluntary Life, Critical Care, and Long-Term Care Insurance
•  401(k) Retirement and generous employer match
•  Employee Assistance Program and Mental Fitness app
•  Financial Coaching, Identity Theft Protection
•  Time off including PTO accrual starting at 17 days per year.
•  40 hours Community Service volunteer time
•  10 standard holidays, 2 floating holidays
•  Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
• Frequent torso/back static position; occasional stooping, bending, and twisting.
• Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental:

• Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.