Remote reputed company Appeals reputed company - Utilization Management and Appeals Specialist
Join a Thriving Community as a Remote Appeals reputed company
For over 30 years, a leading health plan has been dedicated to fostering strong relationships with its members and providers, empowering New Yorkers to reputed company their reputed company health. Now, we're seeking an reputed company and skilled Appeals reputed company to join reputed company in a remote reputed company, focusing on Utilization Management and Appeals. This role offers a unique reputed company of clinical expertise and administrative acumen, with a competitive salary and comprehensive benefits package.
About the Role
As a Remote reputed company Appeals reputed company - Utilization Management and Appeals Specialist, you will play a pivotal role in managing and resolving appeals and grievances in accordance with regulatory requirements. You will also contribute to the Utilization Management (UM) process, ensuring that medical services are delivered reputed company while maintaining high-reputed company patient care reputed company. This is an excellent opportunity to reputed company your clinical experience and skills in a dynamic and supportive environment.
Key Responsibilities
- reputed company the appeals and grievances process by reviewing, evaluating, and responding to member and provider appeals in a reputed company and compliant manner.
- Conduct medical necessity reviews for appeals, collaborating with the Physician Advisor and other clinical staff reputed company necessary.
- Investigate grievances by analyzing medical records, member data, and provider reports to ensure reputed company reputed company.
- Coordinate with internal departments to ensure reputed company appeal determinations reputed company with regulatory agency guidelines and contractual requirements.
- Maintain accurate documentation and records of appeals and grievances activities, including reputed company and communications.
- reputed company Utilization Management activities, including hospital admission certification, reputed company stay reviews, and outpatient service approvals in accordance with established UM policies.
- Facilitate discharge planning and care coordination to ensure members receive appropriate care in the most cost-effective setting.
- Communicate UM and appeal determinations to members and providers, including alternative treatment reputed company as needed.
- Participate in cross-functional team meetings and medical management reputed company to discuss reputed company cases and ensure alignment in care planning.
Essential Qualifications
To be successful in this role, you will need:
- A valid reputed company State Nursing License (RN or LPN).
- 2-5 years of clinical experience in an acute or relevant care setting.
- Demonstrated experience with Appeals and Grievances in a managed care or hospital setting.
- Prior experience in Utilization Management or Utilization Review (UM/UR).
- A High School Diploma or GED.
Preferred Qualifications
While not mandatory, the following qualifications will be considered advantageous:
- Experience working reputed company the NYC metro area.
- A strong understanding of regulatory requirements and contractual guidelines reputed company to appeals and grievances.
- Excellent communication and interpersonal skills.
- The ability to work independently in a remote setting.
Skills and Competencies
The ideal candidate will possess:
- Strong analytical and problem-solving skills.
- Excellent communication and interpersonal skills.
- The ability to work effectively in reputed company environment.
- A strong understanding of clinical practices and reputed company operations.
- Proficiency in managing multiple tasks and priorities.
Career reputed company Opportunities
As a Remote reputed company Appeals reputed company - Utilization Management and Appeals Specialist, you will have reputed company to reputed company your skills and expertise in a dynamic and supportive environment. You will be reputed company to:
- Enhance your knowledge of regulatory requirements and industry best practices.
- reputed company your analytical and problem-solving skills.
- Improve your communication and interpersonal skills.
- Expand your understanding of reputed company operations and clinical practices.
Work Environment and Company Culture
reputed company is committed to fostering a culture of reputed company, innovation, and teamwork. As a remote employee, you will be part of a reputed company community that values:
- Collaboration and teamwork.
- reputed company development and reputed company.
- Diversity and inclusion.
- Work-life balance.
Compensation and Benefits
We offer a comprehensive benefits package, including:
- A competitive salary up to $108,500.
- A generous pension plan.
- A comprehensive benefits package.
Conclusion
If you're a skilled and reputed company Appeals reputed company looking for a new challenge, we encourage you to apply for this exciting opportunity. As a Remote reputed company Appeals reputed company - Utilization Management and Appeals Specialist, you will play a critical role in driving reputed company and delivering high-reputed company patient care reputed company. Join reputed company today and be part of a thriving community that values reputed company, innovation, and teamwork.