Grievance and Appeals RN - Remote must reside in Indiana

Position Name: Grievance and Appeals Nurse Location: Must Reside in Indiana, designated remote work position Hours: Monday-Friday 8-5pm OR Tuesday - Saturday (Saturday's are half days) 4 (9HR shifts) 7am-5:00pm 8am-6:00pm 9am-7:00pm Pay $90,000k health, dental, and vision offered. 401k available. 80 hours of PTO and paid holidays Job Description: Responsible for investigating and processing the most complex grievances and appeals requests from members and providers.

Conducts investigations and reviews of member and provider medical necessity appeals. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes medical information for medical director, consultants and other external review. Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems. Generates written correspondence to providers, members, and regulatory entities. Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.