RN, Registered Nurse Appeals

Description

Location : This position is located at our Dublin, OH campus with hybrid flexibility.

Multistate Licensure : Quantum Health nurses must be willing and able to obtain and maintain nursing licensure in multiple states, as required by the business. All application and filing fees will be paid by Quantum Health.

Who we are

Founded in 1999 and headquartered in Central Ohio, w e're a privately-owned , independent healthcare navigation organization . We believe that no one should have to navigate the cost and complexity of healthcare alon e, and w e're on a mission to make healthcare simpler and more effective for our millions of members . Our big-hearted, tech-savvy team fight s to ensure that our members get the care they need, when they need it, at the most affordable cost - that's why we call ourselves Healthcare Warriors .

We're committed to building diverse and inclusive teams - more than 2,000 of us and counting - so if you're excited about this position, we encourage you to apply - even if your experience doesn't match every requirement.

About the role

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 bring

What's in it for you

What you should know

Phone Screen >

Online Assessment(s) >

Interview(s) >

Offer >

Background Check.

Reasonable Accommodation : Should you require reasonable accommodation(s) to participate in the application / interview / selection process, or in order to complete the essential duties of the position upon acceptance of a job offer, click here to submit a recruitment accommodation request.

Recruiting Scams : Unfortunately, scams targeting job seekers are common. To protect our candidates, we want to remind you that authorized representatives of Quantum Health will only contact you from an email address ending Quantum Health will never ask for personally identifiable information such as Date of Birth (DOB), Social Security Number (SSN), banking / direct / tax details, etc. via email or any other non-secure system, nor will we instruct you to make any purchases related to your employment. If you believe you've encountered a recruiting scam, report it to the Federal Trade Commission and your state's Attorney General .