Clinical Appeals Nurse - Remote / Telecommute

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. accommodations may be made to enable individuals with disabilities to perform the essential functions. High School Diploma. Experience: 2 years medical-surgical or similar clinical experience OR 3 years experience in mental health, psychiatric setting. Preferred Qualifications: 2 years experience in Medical Review, Utilization Management or Case Management at Client Client, or similar Managed Care organization or hospital preferred. BSN/MSN Degree. Knowledge, Skills and Abilities: Knowledge and understanding of medical terminology., Advanced Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals., Proficient Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task. , Proficient Ability to effectively communicate and provide positive customer service to every internal and external customer., Advanced Knowledge of Microsoft Office programs., Proficient Excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions., Proficient The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging. Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required. CCM - Certified Case Manager Upon Hire Preferred. LNCC - Legal Nurse Consultant Certified Upon Hire Preferred.

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