Utilization Review and Appeals Nurse - Remote

Martin’s Point Health Care•Portland, ME

9d•Remote

About The Position

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. Position Summary The Utilization Appeals Review Nurse will be responsible for clinical review of member and provider appeals and/or claims disputes. Collaborating with our team of Medical Directors and internal stakeholders, you will use your clinical expertise to apply Martin’s Point medical policies, CMS and TRICARE regulations to deliver accurate, timely, and compliant appeal or claims disputes decisions.

Requirements

Associate Degree in Nursing (ADN)
Active, unrestricted Compact Registered Nurse (RN) license.
3+ years of RN clinical experience, preferably in a hospital setting, along with experience in utilization management in a health plan UM department and in managing appeals or disputes
Thorough understanding of CMS Medicare Advantage regulations (Parts C & D) and NCQA guidelines
Thorough knowledge of MCG, Interqual of other clinical guidelines
HIPAA & privacy requirements
Concurrent, prior authorization and appeals review
Critical thinking and case analysis
Clinical writing and summarization
Electronic UM systems
Ability to extract relevant clinical facts from progress notes, labs, imaging, and treatment plans.
Correct use of MCG, and Martiin’s Point medical policies to determine medical necessity.
Ability to identify inconsistencies, missing information, or red flags in documentation
Understanding appeal levels, timeframes, coverage rules, and documentation requirements.
Ability to produce rationales that meet CMS, TRICARE, and NCQA standards
Ability to write clear, defensible rationales that explain the clinical and regulatory basis for the determination.
Ability to write concise, objective, and compliant appeal rationales
Ability to analyze data metrics, outcomes, and trends.
Ability to prioritize time and tasks efficiently and effectively.
Ability to manage multiple demands.
Ability to function independently.

Nice To Haves

Bachelor’s degree in nursing preferred
Coding/CPC preferred
Tricare regulation experience preferred
MCQA standards experience preferred
Claims disputes review experience preferred

Responsibilities

Responsible for the review and resolution of clinical appeals and disputes
Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues.
Ensures care delivery aligns with specific line-of-business benefits while maintaining full compliance with contractual and regulatory standards, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable.
Stays current with industry regulations and accreditation standards to ensure continuous operational compliance
Consistently delivers high-quality outcomes that meet or exceed established departmental benchmarks and performance standards.
Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings.
Independently coordinates the clinical resolution with internal/external clinician support as required.
This position will be accountable for appeals, claims disputes, and QOC review
Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
Assumes extra duties as assigned based on business needs.