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Job Requirements of RN - Appeals & Post Service Review:
-
Employment Type:
Contractor
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Location:
Jacksonville, FL (Onsite)
Do you meet the requirements for this job?
RN - Appeals & Post Service Review
Careers Integrated Resources Inc
Jacksonville, FL (Onsite)
Contractor
Job Title: RN - Appeals & Post Service Review
Location: Jacksonville, FL 32246
Duration: 3 Months+ of Contract (Possible Extension)
Job Summary:
- The Appeals & Post Service Review RN role is centered on the daily case review for appeals from members, members' beneficiary representatives, and providers in order to meet timeliness and documentation compliance metrics.
- In addition, the role is responsible for post service review and clinical provider appeals.
- Facilitates final determination based on findings and procedures within strict timelines established by regulatory requirements.
- Authors final appropriate statement supporting final determination based on appropriate criteria or medical director determination.
Essential Functions:
The essential functions listed represent the major duties of this role; additional duties may be assigned:
- Reviews and researches appeals to reach timely, appropriate determination.
- Reviews and researches member and provider appeals and their medical documentation, abstracts pertinent data into the documentation system, and reviews with Medical Director to reach a final determination.
- Processes Post Service reviews, abstracts pertinent data into the documentation system, reviews with Medical Director, as appropriate, to reach determination.
- Accesses Legacy or Diamond to review how claim was originally processed as needed.
- Interprets Client's Medical Coverage Guidelines for staff.
- Responsible for research, preparation, and presentation of clinical appeal cases (medical necessity and experimental/investigational procedures).
- Works with business partners across the organization, as needed, to gather data as input for final determination.
- Prepares Independent Review Entity (Maximus) packages and assists team members with case review to ensure all documentation is included in the package.
- Follows regulatory requirements as appropriate and corporate values, policies, and procedures.
- Ensures final determination is reached and communicated within strict timelines.
Qualifications & Skills:
Education:
- Related Bachelor's degree or additional related equivalent work experience (Required).
Licensure & Certifications:
- RN - Registered Nurse – State Licensure and/or Compact State Licensure (Required).
- State of Florida Licensed Registered Nurse, Unrestricted (Required).
Must:
- Previous CMS experience and review of all organization determinations, including pharmacy reviews.
- Top candidates are those that have Jiva, Seibel, and Diamond experience.
- Remote - Florida.
- Must have a FL RN License - Unrestricted or Nursing Compact license.
Preferred:
- Ability to work with multiple screens and systems.
- Managed care experience, including InterQual, NCD, and LCD medical review criteria.
- Understanding of Regulatory Agencies.
- Medicare Advantage Experience.
- Prior FLBL experience.
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