Medicare Advantage Appeals And Grievance Nurse

• Employer covers 90% of monthly premium cost for health, dental and vision plans
• Employee discount program
• Annual employee bonus program to reward success
• Paid parental leave and adoption leave with adoption financial assistance
• Robust 401(k) with 50% match and end of year discretionary employer contribution
• Time away from work including paid holidays, paid time off and volunteer time off
• Competitive benefits package with day one eligibility
• Professional development courses, mentorship opportunities and tuition reimbursement program

This position serves as a clinical and administrative subject matter expert for grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution and responses are processed promptly in accordance with Federal and State regulatory requirements/guidelines and CMS requirements/guidelines and timelines.

• Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
• Acts as a member advocate addressing member or provider concerns
• Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each day.
• Recognizes potential quality of care concerns
• Utilizes multiple internal and external computer applications and programs
• Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations.
• Maintains a thorough understanding of Health Plan operations and business unit processes, workflows and system requirements, including, but not limited to, plan benefits, authorizations, referrals, network and non-network provider claims, and regulatory compliance.
• Develops timely and professional documentation and correspondence that ensures accuracy, completeness and conformance to quality and regulatory standards
• Meets established productivity and quality standards
• Participates in CMS and other audits and related activities as required.
• Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals.
• Reviews medically appropriate clinical guidelines and prepares cases for Medical Director and/or External Review
• Provides training, leadership and mentoring for less experienced appeal RN and administrative staff.
• Formulates determination language that resolves member or provider issues in a manner consistent with regulatory and accrediting agency requirements
• Performs other duties as assigned

• Knowledge of MCG, InterQual or other medically appropriate clinical guidelines
• 3 years of acute care or outpatient clinical experience
• Strong critical thinking, analytical, research and organizational skills
• State of Missouri & Kansas Licensure
• 2 years of appeals and UM experience in a payer-based environment
• Associates degree in Nursing Required
• Excellent written and oral communication skills
• Proficiency with PC-based software programs including Word, Excel and Outlook
• Active, unrestricted Registered Nurse License
• Knowledge of CMS, URAC, NCQA® , state and federal regulations/guidelines

• Multi – state licensure
• Bachelor’s degree in Nursing