RN Clinical Appeals in Meridian, ID at Volt

Date Posted: 6/25/2020

Job Snapshot

  • Employee Type:
    Contingent
  • Location:
    Meridian, ID
  • Duration:
    24 weeks
  • Date Posted:
    6/25/2020
  • Job ID:
    234928
  • Pay Rate
    $36.0/Hour
  • Contact Name
    Volt Branch
  • Phone
    208-375-9930

Job Description

Want to Join a Winning Team?

Are you Detail-Oriented? Do you like the analytical side of things?

Contact Volt today to apply for the following position(s):

RN Clinical Appeals

Start Date: ASAP ( Mon- Sat with rotating Saturdays 8am - 5pm)

Pay rate: $30-36/hr

Contract assignment 6 months or more! Full time opportunities may be possible for a few of the high performers!

** This position starts remote and then moves on-site. Exact details TBD **

POSITION PURPOSE:

Under limited supervision, manage the clinical review of provider and member appeals for all product lines to ensure timely resolution within required turnaround times, utilizing member contract or EOC, published clinical criteria, medical policy or Medicare coverage criteria, as applicable.

QUALIFICATIONS:  (Minimum qualifications required for the job)

  • Experience: Three years’ clinical nursing experience to include:
    • One year utilization management or discharge planning; and
    • Medical and surgical inpatient and/or outpatient care; or
    • Specialty care (occupational health, rehabilitation, orthopedic, neurological surgical nursing, or behavioral health)
  • Education:  Degree in Nursing
  • Licenses/Certifications:  Valid Idaho Registered Nurse License (RN)

Knowledge, Skills and Abilities (KSAs):

Knowledge of:

  • Claim review processes and workflow
  • Clinical criteria and medical policy
  • Group process and team dynamics
  • Utilization Management
  • Quality Improvement
  • Center for Medicare and Medicaid Services (CMS)

Skills:

  • Interpersonal, verbal, and written communication
  • Analytical
  • Problem solving
  • Organizational
  • Independent & critical thinking
  • Self-motivation
  • Collaboration
  • Project management
  • Microsoft Office (Word, Excel, Outlook) – Basic

Ability to:

  • Schedule time effectively
  • Handle multiple projects simultaneously and prioritize work appropriately
  • Work well in a highly integrated team environment
  • Handle diverse activities on a daily basis
  • Communicate with diverse audiences

Preferred Requirements:

  • Certified Professional Coder (CPC) and/or Certified Professional Coder – Hospital (CPH)
  • Prior experience as a pre-service or post-service clinical reviewer
  • Knowledge of Facets claim and inquiry review applications
  • Medical record review
  • National Commission on Quality Assurance (NCQA) accreditation standards
  • Managed care delivery systems

ACCOUNTABILITIES:

Review member and provider appeals submitted from Customer and Provider Services.  Research, document, and complete the appeal review.  Coordinate as needed with physician review.

Create episodes in UM system for management and documentation of the clinical review process.

Review correspondence and medical records autonomously using sound judgment and good decision making and problem solving skills to assure a quality response.

Use clinical judgment along with appropriate review criteria, medical policy, or Medicare coverage criteria to confirm medical necessity and appropriateness of reviewed service.

Manage appeal inventory of assigned product lines to achieve required turnaround time.

Provide comprehensive reviews and timely referrals to physician review.

Perform weekly sample audits of approved and denied post-service clinical review claims.

Identify and refer cases to the Special Investigation Unit.

Actively participate in interdepartmental “roundtable” process improvement activities.

Document and report potential quality of care or service issues to the Quality Manager.

Attend, participate, and share information with team from assigned committees.

Perform other duties and responsibilities as assigned.

STATEMENT OF OTHER DUTIES

This document describes the major duties, responsibilities and authorities of this job, and is not intended to be a complete list of all tasks and functions.  It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.

All employees are required to familiarize themselves and continually comply with all federal and state health care laws, regulations and rules (including Medicare and Medicaid billing requirements if applicable to the employee's job duties).  Any employee who becomes aware of possible noncompliance with applicable laws is required to promptly report such possible noncompliance to his or her immediate manager or Compliance Hot Line.  No adverse action or any form of retaliation shall be taken against any employee because of that person's good faith report of possible noncompliance.

REASONABLE ACCOMMODATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed above are representative of the knowledge, skill and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Interested Candidates can apply by sending a resume toboise@volt.com OR applying via indeed OR via jobs.volt.com. We are also available by phone or text at 208-375-9930.  HURRY THESE SPOTS WILL FILL FAST!!!

“Volt is an equal opportunity employer”