Appeals Nurse 2

Employment Type: Full-time Work Style: Remote Work Days/Hours: Monday – Friday; 8:00 a.m. - 5 p.m. Eastern Time Pay Range: [Information not provided] Salary: [Information not provided] Location Type: [Information not provided]

Position Overview

Become a part of our caring community and help us put health first. The Appeals Nurse 2 resolves clinical complaints and appeals. This role's 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.

Responsibilities

• Review medical documentation, obtain additional information that may be needed, including timeframes when a 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 ensure adherence to TRICARE policy requirements.
• Identify and address discrepancies by sending cases 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 timeframes, processes, and review determinations. Provide education on alternatives for services that may not be approved, if needed.
• Maintain knowledge of TRICARE, all HGB policies and procedures, as well as medical necessity review criteria and privacy requirements.
• Coordinate the clinical resolution with internal/external clinician support as required.
• Document and summarize investigation results to all parties involved in the case.
• Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Make decisions regarding own work methods, occasionally in ambiguous situations, requiring minimal direction and receiving guidance where needed.
• Follow established guidelines/procedures.

Requirements

• Required Qualifications:
  • U.S. Citizenship (required due to Department of Defense contract).
  • Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Service).
  • Active unrestricted RN license.
  • 3 years of clinical RN experience.
  • Proficient with Microsoft Office products including Word, Excel, and Outlook.
• Preferred Qualifications:
  • Appeals/Utilization Review/Quality Management experience.
  • Previous claims experience.
  • Experience working with MCG guidelines.
  • Working knowledge of ICD-9 or ICD-10, HCPCS, DRG use.
  • Experience with TRICARE contracts and/or the military health care delivery system.
  • Knowledge of TRICARE policies and programs.
  • Bachelor's degree.

Work at Home Requirements

To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended.

• Wireless, wired cable, or DSL connection is suggested.

• Satellite, cellular, and microwave connections can be used only if approved by leadership.

• Associates who live and work from home in the states of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Additional Information

• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
• Note: HGB is not authorized to do work in Puerto Rico per our government contract and cannot hire candidates currently living in Puerto Rico.

Company Information

[Company information not provided in the original text.]