Appeals Nurse Consultant - MUST LIVE IN FLORIDA

The Appeals Nurse Consultant is responsible for the intake, investigation, and resolution of appeals, complaints, and grievances for all products, which may involve multiple issues and require coordination across various business units. This role ensures timely, customer-focused responses and identifies trends to recommend solutions. Specifically, the consultant reviews and resolves clinical documentation, clinical complaints, and appeals by interpreting data from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements. They coordinate clinical resolutions with internal and external clinician support, gather data by navigating multiple system applications, and obtain additional information from providers, vendors, or internal departments. The consultant accurately applies review requirements to ensure cases are reviewed by a practitioner with the appropriate clinical expertise and commands a comprehensive knowledge of delegation arrangements, coding logic, contracts, clinical criteria, benefit plan structure, and regulatory requirements. They proactively apply regulatory and accreditation standards, condense complex information into a clear clinical picture, and coordinate the appeal process in collaboration with various stakeholders in compliance with state regulations and benefit plan designs. The consultant reports findings, responds to rebuttal issues, and makes recommendations for improvement, while also identifying trends and emerging issues to provide input on potential solutions.