Utilization Review and Appeals Nurse - Remote

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

The Utilization Appeals Review Nurse will be responsible for clinical review of member and provider appeals and/or claims disputes. Collaborating with our team of Medical Directors and internal stakeholders, you will use your clinical expertise to apply Martin’s Point medical policies, CMS and TRICARE regulations to deliver accurate, timely, and compliant appeal or claims disputes decisions. Job Description PRIMARY DUTIES AND RESPONSIBILITIES: Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

Responsible for the review and resolution of clinical appeals and disputes 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. Ensures care delivery aligns with specific line-of-business benefits while maintaining full compliance with contractual and regulatory standards, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. Stays current with industry regulations and accreditation standards to ensure continuous operational compliance Consistently delivers high-quality outcomes that meet or exceed established departmental benchmarks and performance standards. Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings. Independently coordinates the clinical resolution with internal/external clinician support as required. This position will be accountable for appeals, claims disputes, and QOC review This is a full-time remote position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time). Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another. Assumes extra duties as assigned based on business needs. Weekend and holiday on-call coverage may be required.