Utilization Reviews Appeals Registered Nurse - Remote | WFH
As an Appeals & Claims UR Nurse, you'll play a pivotal role in investigating and reviewing clinical appeals and post-claim cases. Your responsibilities include utilizing your clinical expertise and established criteria to assess the medical appropriateness of healthcare services, spanning from inpatient and lower level of care admissions to various outpatient and specialty services. Working... remotely, you'll collaborate with Oscar medical providers and internal teams, ensuring seamless execution of your duties. You'll be reporting to the Clinical Appeals Manager, joining a dynamic team committed to maintaining high standards of healthcare delivery. Location: This is a remote position open to residents of the following states: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, or Washington, D.C. Compensation: The base pay for this role ranges from $35 to $45.94 per hour. Additionally, you'll be eligible for employee benefits and enjoy monthly vacation accrual of up to 10 days per year.
Responsibilities
Conduct medical necessity reviews and level of care assessments for requested services, adhering to Oscar Clinical Guidelines and Milliman Care Guidelines. Gather essential information through telephone and fax communication to evaluate a member's clinical condition and apply evidence-based guidelines accordingly. Meet decision-making service level agreements (SLAs) and refer members for further care engagement when necessary. Ensure compliance with all relevant laws and regulations. Perform other assigned duties as needed.
Qualifications
Hold an active, unrestricted RN licensure from the United States in one of the specified states OR possess an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). Have an Associate Degree in Nursing, Graduate of Accredited School of Nursing, or successful completion of a Diploma Program in Practical Nursing from an Accredited School of Nursing. Ability to obtain additional state licenses as required by business needs. Possess at least 1 year of utilization review experience in a managed care setting and 2+ years of clinical experience, including a minimum of 1 year of clinical practice in an acute care setting such as the ER or hospital. Bonus Points For BSN qualification. Previous experience in conducting concurrent or inpatient reviews for a managed care plan. Equal Opportunity Employer Statement We embrace diversity and foster an inclusive environment where everyone feels empowered to be their authentic selves. We're dedicated to transforming healthcare, leveraging our unique backgrounds and perspectives to drive positive change. Pay Transparency Final compensation offers, within the specified base pay range, are determined based on factors including relevant skills, education, and experience.
Benefits
Full-time employees are entitled to a comprehensive benefits package, including medical, dental, and vision coverage, paid holidays, sick leave, parental leave, 401(k) participation, life and disability insurance, and wellness benefits. Employment Type: Full-Time Apply Job! For more such jobs please click here!