Remote New York Appeals Nurse - Utilization Management and Appeals Specialist

Join a Thriving Community as a Remote Appeals Nurse For over 30 years, a leading health plan has been dedicated to fostering strong relationships with its members and providers, empowering New Yorkers to achieve their optimal health. Now, we're seeking an experienced and skilled Appeals Nurse to join our team in a remote capacity, focusing on Utilization Management and Appeals. This role offers a unique blend of clinical expertise and administrative acumen, with a competitive salary and comprehensive benefits package. About the Role As a Remote New York Appeals Nurse - Utilization Management and Appeals Specialist, you will play a pivotal role in managing and resolving appeals and grievances in accordance with regulatory requirements. You will also contribute to the Utilization Management (UM) process, ensuring that medical services are delivered efficiently while maintaining high-quality patient care outcomes. This is an excellent opportunity to leverage your clinical experience and skills in a dynamic and supportive environment. Key Responsibilities Lead the appeals and grievances process by reviewing, evaluating, and responding to member and provider appeals in a timely and compliant manner. Conduct medical necessity reviews for appeals, collaborating with the Physician Advisor and other clinical staff when necessary. Investigate grievances by analyzing medical records, member data, and provider reports to ensure proper resolution. Coordinate with internal departments to ensure all appeal determinations comply with regulatory agency guidelines and contractual requirements. Maintain accurate documentation and records of appeals and grievances activities, including decisions and communications. Perform Utilization Management activities, including hospital admission certification, continued stay reviews, and outpatient service approvals in accordance with established UM policies. Facilitate discharge planning and care coordination to ensure members receive appropriate care in the most cost-effective setting. Communicate UM and appeal determinations to members and providers, including alternative treatment options as needed. Participate in cross-functional team meetings and medical management rounds to discuss complex cases and ensure alignment in care planning. Essential Qualifications To be successful in this role, you will need: A valid New York State Nursing License (RN or LPN). 2-5 years of clinical experience in an acute or relevant care setting. Demonstrated experience with Appeals and Grievances in a managed care or hospital setting. Prior experience in Utilization Management or Utilization Review (UM/UR). A High School Diploma or GED. Preferred Qualifications While not mandatory, the following qualifications will be considered advantageous: Experience working within the NYC metro area. A strong understanding of regulatory requirements and contractual guidelines related to appeals and grievances. Excellent communication and interpersonal skills. The ability to work independently in a remote setting. Skills and Competencies The ideal candidate will possess: Strong analytical and problem-solving skills. Excellent communication and interpersonal skills. The ability to work effectively in a team environment. A strong understanding of clinical practices and healthcare operations. Proficiency in managing multiple tasks and priorities. Career Growth Opportunities As a Remote New York Appeals Nurse - Utilization Management and Appeals Specialist, you will have the opportunity to develop your skills and expertise in a dynamic and supportive environment. You will be able to: Enhance your knowledge of regulatory requirements and industry best practices. Develop your analytical and problem-solving skills. Improve your communication and interpersonal skills. Expand your understanding of healthcare operations and clinical practices. Work Environment and Company Culture Our company is committed to fostering a culture of excellence, innovation, and teamwork. As a remote employee, you will be part of a vibrant community that values: Collaboration and teamwork. Professional development and growth. Diversity and inclusion. Work-life balance. Compensation and Benefits We offer a comprehensive benefits package, including: A competitive salary up to $108,500. A generous pension plan. A comprehensive benefits package. Conclusion If you're a skilled and experienced Appeals Nurse looking for a new challenge, we encourage you to apply for this exciting opportunity. As a Remote New York Appeals Nurse - Utilization Management and Appeals Specialist, you will play a critical role in driving success and delivering high-quality patient care outcomes. Join our team today and be part of a thriving community that values excellence, innovation, and teamwork. Ready to take the next step in your career? Apply now! Apply for this job