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Appeal Nurse Reviewer
Chicago, IL

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Posted 4/19/2017

Required Skills

  • Active, unrestricted Illinois Nursing / Registered Nurse licensee
  • Bachelor’s degree in nursing at a minimum 
  • Working knowledge of national practice guidelines and or UM medical necessity guidelines such as Milliman, InterQual and or Apollo
  • 3-5 years clinical experience
  • Previous experience handling appeals for the Medicaid and Medicare population
  • Experience in a managed care environment
  • Familiarity with NCQA standards
  • High level of organizational skills and able to manage multiple priorities
  • Effective verbal and written skills
  • Ability to effectively prioritize and execute tasks in a fast paced environment

Job Description

  • Investigate and resolve medical necessity appeals and maintain documentation
  • Collaborate with internal and external medical colleagues and Medical Directors in order to maintain a timely process
  • Respond to member, provider and other customer telephone inquiries regarding status, process and outcomes of appeals
  • Identify potential quality of care issues within medical appeals: escalate as appropriate
  • Participate in departmental audits and regulatory site visits
  • Perform trend analysis and make recommendations for process improvements
  • Resource to non-clinical members of the department

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