Job Title: Appeals Nurse Location: Remote - 1080 Jordan Creek Pkwy, West Des Moines, IA 50266 Schedule: Monday–Friday | 8 am to 5pm CST Duration: 10 Months Contract (Possibility to extend or convert to FTE) Payrate: $40-45/hr Note: for the Onsite work arrangement, workers would would only be required to work onsite if they are hired after the contract. Temp workers are working fully remote. - work address is 1080 Jordan Creek Pkwy West Des Moines FTE Salary Conversion Band : $70,100 to 126,200 Position Purpose: The team is fully remote and highly experienced. They collaborate effectively, demonstrate strong accountability, and consistently work well together to manage complex appeals. Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met. Key Responsibilities: • Review and process Iowa Medicaid Member Appeals • Member appeal requests are received and assigned by the team lead; the appeals nurse is responsible for working the appeal start to finish. • Outreach attempts are made to member/provider. • A clinical review is completed and case sent to specialty review/MD. • Appeals nurse will write determination letters and close the case. • Review clinical data to determine claim payment based on company policies and • National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review • Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received • Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions • Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution • Gather and prepare case information for Administrative Law Hearings • Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database • Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements Required Skills/Qualifications: • Associates Degree, GED/HS Diploma as long as they are LPNs • Required: LPN, Preferred: RN • At least 2 years nursing experience, UM experience helpful • Customer service • Time management • Computer skills/ability to learn new systems
IMCS Group is a healthcare services company providing managed care, clinical review, and administrative support services, hiring for remote nursing roles such as appeals and utilization review.
