RN (Appeals & Post Service Review)

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.

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)

Required Skills & Experience:

• 2+ years related clinical work experience

• Demonstrated extensive experience with Medical Coverage Guidelines as it relates to medical necessity and experimental/investigational procedures

• Demonstrated ability to interact with internal and external customers in a highly professional manner

• Demonstrated ability to simultaneously interact with multiple research and processing systems

• Knowledge of HIPAA and ERISA requirements

• Knowledge of regulatory requirements

• Ability to work within strict timeframes

• Ability to use Microsoft Office (Word, PowerPoint, Excel)

Preferred Skills & Experience:

• None listed explicitly