Clinical Registered Nures (Rn) Appeals & Grievences - Remote

Investigate and resolve medical necessity member appeals. Ensure compliance with state and federal guidelines, including Centers for Medicare and Medicaid Servicesrequirements. Maintain all appeals documentation according to external agency requirements.

• Identify potential quality of care issues within medical appeals; escalate as appropriate.
• Respond to internal and external inquiries, assist with special member cases, and suggest resolutions via telephone or written communication.
• Complete required compliance training in a timely manner
• Ensure confidentiality of member and company proprietary information is maintained
• Prepares recommendations to either uphold or deny appeal and forwards to Medical Director as needed.
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
• Documents and logs appeal/grievance information on relevant tracking systems.
• Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and members. Approach work in a collaborating and caring manner interacting with insight, sincerity, and compassion. Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering environment where the focus is on solving problems and learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of CCA's mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and openness to change. Represent CCA and its clinical affiliates with professionalism. Keep current and proficient with necessary skills and knowledge. Self- identify training and development needs relevant to work area and responsibilities. Adhere to all applicable compliance requirements including but not limited to:
• Participate in telephonic Administrative Law Judge Hearings and present oral arguments as needed.
• Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
• Generates appropriate written correspondence to providers, members, and regulatory entities.
• Participate in departmental audits in preparation of regulatory site visits.
• Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary.
• Adhere to CCA's Policy & Procedures
• Promptly, in good faith, report any instances of suspected fraud, waste and abuse; suspected privacy and/or security incidents; or any compliance concerns identified
• Utilize industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, Interqual, and best practice standards, as well as a broad knowledge base and sound clinical judgment in reviewing medical records and writing appeals.
• Extrapolates and summarizes medical information for medical director, consultants and other external review.
• Review Code of Conduct at least annually and promote and enforce CCA's Code of Conduct Promote and enforce CCA's compliance program

• 5+ years of clinical nursing experience is strongly
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
• Ability to work independently and make decisions
• Experience in Medicaid/Medicare grievances and appeals and/or Utilization Review is strongly preferred.
• Strong interpersonal, verbal and written communication skills preferred
• Current active unrestricted Massachusetts RN license.,AS/BS in Nursing preferred.
• Proficiency in Microsoft Word, Excel and Outlook.
• Comfort working in a team-based environment
• Working knowledge of and ability to navigate through the healthcare system
• English required, bilingual preferred
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, and analytical
• 3+ years of nursing experience in a Managed Care setting is required