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The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Appeals Nurse 2 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. Coordinates the clinical resolution with internal/external clinician support as required. Documents and summarizes to all parties involved in the case the investigation's results. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
KEY ACCOUNTABILITIES
Review medical documentation, obtain additional information that may be needed including timeframes when physician is available for peer to peer review, and forward to physician review companies or TQMC. Monitor and follow up for timeliness and review response and determination to insure follows TRICARE policy requirements. If discrepancies found will send back for follow up review and correction as needed.
Review, coordinate, arrange and maintain Second level Review /Reconsideration records and patient and provider response letters
Provide education to beneficiaries and providers regarding second level review time frames, process and review determinations. If needed provide education on alternatives for services that may be not be approved
Maintain knowledge of TRICARE, all HGB policies and procedures as well as medical necessity review criteria and privacy requirements
Use your skills to make an impact
Required Qualifications
Our Department of Defense contract requires U.S. Citizenship
Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico.
Active unrestricted RN license
3 years of clinical RN Experience
Appeals nursing experience
Claims experience
Proficient with Microsoft Office products including Word, Excel and Outlook
Preferred Qualifications
Utilization Review/Quality Management experience
Experience working with MCG guidelines
Working knowledge of ICD-9 or ICD-10, HCPCS, DRG use
Experience with TRICARE contracts and/or the military health care delivery system
Knowledge of TRICARE policies and programs
Bachelor's degree
Additional Information
Work Style : Remote
Work Days/Hours: Monday - Friday; 8:00 a.m.-5 p.m. Eastern Standard Time
Work at Home Requirements
To ensure Hybrid Office/Home associates' ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
Satellite, cellular and microwave connection can be used only if approved by leadership
Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
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Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
