Appeals Nurse RN

Profile

Description

Welcome Bonus:

$2,500 for external candidates

(does not apply to rehires)

Location:

All clinical positions are

located

on site at our Dublin, Ohio campus

We’re

on a mission to make healthcare simpler and more effective. We fight to ensure our members get the care they need, when they need it, at the most affordable cost –

that’s

what makes us Healthcare Warriors™. If

you’d

like to join us,

we’d

love to talk to you – even if you

don’t

match

every single requirement. 

The

Registered Nurse (RN) – Appeals

is responsible for

managing all clinical appeal requests according to Quantum Health’s defined process for the receipt, logging, preparing for review,

evaluation

 and response. This critical clinical subject matter expert works to increase the consistency,

efficiency

 and appropriateness of responses for all appeal service requests. 

What

you’ll

do

Review and process all appeal requests; Prepare requests for review by researching Specific Plan Detail (SPD) provisions, applicable criteria, analyzing the basis for appeal and preparing a written summary of each case. 

Assure

timely

processing and response to appeal requests. 

Communicate with

member

provider

facility

, and all internal work groups

regarding

appeal requests/outcomes. 

Collaborate with Medical Directors, Physician reviewers, External Medical Directors, and Independent Review Organization (IRO) to process all requests requiring physician review. 

Identify

care coordination and case management opportunities.

Maintain a working knowledge of all clinical processes and workflows, employer benefit plans and related documentation.  

Participate in educational training with clinical staff

regarding

the appeal process; Partner with the clinical operations managers to

identify

coaching opportunities for the clinical services team,

identify

trends, and improve processes.

Assist

pre-certification team as needed with medical reviews, 

assist

 with pre-certification training, serve as enhanced pre-certification trainer for new nurses,

provide

coaching to care coordination nurses on appeal cases, etc.  

All other duties as assigned. 

What

you’ll

need

Licensure: Active license in good standing as a Registered Nurse (RN

in the State of Ohio required

Education: Bachelor of Science in Nursing (BSN) degree in nursing preferred 

3 years of clinical experience with direct patient care in a hospital setting

required

Experience working in the clinical review and/or appeal process, ideally in a health insurance setting preferred. 

Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently. 

Excellent verbal and written communication skills. Comfortable communicating with members

and providers via phone regularly throughout the day.

Trustworthy and accountable behavior, capable of viewing and

maintaining

confidential personal information daily

Ability to communicate effectively with members and providers in implementing clinical services; Translate complex clinical concepts for non-clinical audiences. 

What’s

in it for you

Compensation:

Competitive base pay, incentive plans and employee referral bonuses.

Coverage:

Health, vision and dental featuring our best-in-class healthcare navigation services, along with life insurance, legal and identity protection, adoption

assistance

, EAP, Teladoc services and more. 

Retirement:

401(k) plan with up to 4% employer match and full vesting on day one.

Balance:

Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.

Development:

Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid

trainings

and leadership development. 

Culture:

Recognition as

a Best

Place to Work for 15 years, dedication to

diversity, philanthropy and sustainability

, and people-first values that drive every decision.  

Environment:

A modern workplace with a casual dress code, open floor plans, full-service dining, free

snacks

and drinks, complimentary 24/7 fitness center with group classes, outdoor walking paths, game room,

notary

and dry-cleaning services and more! Check out our home:

https://youtu.be/xRnbvCW_YgA

What you should know

Internal Associates:

Already a Healthcare Warrior? Apply internally through Jobvite.

Process:

  Application > Phone Screen > Online Assessment(s) > Interview(s) > Offer > Background Check

Diversity,

Equity

and Inclusion:

Quantum Health welcomes everyone. We value our diverse team and suppliers,

we’re

committed to empowering our ERGs, and

we’re

proud to be an

equal opportunity employer

Agencies:

 Quantum Health does not accept unsolicited resumes or outreach from

third-parties

. Absent a signed MSA and request/approval from Talent Acquisition to

submit

candidates for a specific requisition, we will not approve payment to any third party. 

Sponsorship:

Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.

*Actual compensation is based on a combination of experience and qualifications

#LI-HW1 #LI-Onsite

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Company info

Quantum Health LLC.
Website : http://quantum-health.com