The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Appeals Nurse 2 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. Coordinates the clinical resolution with internal/external clinician support as required. Documents and summarizes to all parties involved in the case the investigation's results. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Review medical documentation, obtain additional information that may be needed including timeframes when physician is available for peer to peer review, and forward to physician review companies or TQMC. Monitor and follow up for timeliness and review response and determination to insure follows TRICARE policy requirements. If discrepancies found will send back for follow up review and correction as needed.
Review, coordinate, arrange and maintain Second level Review /Reconsideration records and patient and provider response letters
Provide education to beneficiaries and providers regarding second level review time frames, process and review determinations. If needed provide education on alternatives for services that may be not be approved
Maintain knowledge of TRICARE, all HGB policies and procedures as well as medical necessity review criteria and privacy requirements
Our Department of Defense contract requires U.S. Citizenship
Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
Active RN license in the state(s) in which the nurse is required to practice
At least 3 years of varied clinical Registered Nurse experience
Proficient with Microsoft Office products including Word, Excel and Outlook
Ability to work independently under general instructions and with a team
Excellent verbal and written communication skills
We will requirefull COVIDvaccinationfor this jobas weare ahealthcarecompany committed to putting health and safety first for our members, patients, associates and the communities we serve.
If progressed to offer, you will be required to provide proof offullvaccination or documentation for amedical or religious exemptionconsiderationwhereallowed by law.Requests for these exemptions should be submitted at least 2 week prior to your scheduled first day of work.
Must ensure designated work area is free from distractions during work hours and virtual meetings. Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required.