Experienced Remote NY Appeals Nurse / Utilization Management Specialist - Appeals and Grievances Management

Join Our Mission to Empower New Yorkers to Live Their Healthiest Lives

For over three decades, our health plan has been dedicated to fostering strong relationships with our members and providers, enabling individuals across New York to achieve optimal health and wellbeing. We're now seeking a skilled and experienced Appeals Nurse / Utilization Management Specialist to join our team in a remote capacity, playing a critical role in our Appeals and Grievances management process.

About the Role

As a Remote NY Appeals Nurse / Utilization Management Specialist, you will work under the guidance of our Vice President of Clinical Services, overseeing the management and resolution of appeals and grievances in accordance with regulatory requirements. This role is multifaceted, requiring a strong background in Appeals and Grievances management, as well as experience in Utilization Management (UM) or Appeals within the NYC metro area. You will be responsible for ensuring that medical services are delivered efficiently while maintaining high-quality patient care outcomes.

Key Responsibilities

• Lead the appeals and grievances process by reviewing, evaluating, and responding to member and provider appeals in a timely and compliant manner.
• Conduct medical necessity reviews for appeals, collaborating with our Physician Advisor and other clinical staff as necessary to ensure informed decision-making.
• Investigate grievances by analyzing medical records, member data, and provider reports to ensure proper resolution and identify opportunities for improvement.
• Coordinate with internal departments to ensure all appeal determinations comply with regulatory agency guidelines and contractual requirements, maintaining the highest standards of quality and compliance.
• Maintain accurate and comprehensive documentation and records of appeals and grievances activities, including decisions and communications.
• Perform Utilization Management activities, including hospital admission certification, continued stay reviews, and outpatient service approvals in accordance with established UM policies and procedures.
• Facilitate discharge planning and care coordination to ensure members receive appropriate care in the most cost-effective setting, optimizing health outcomes and patient satisfaction.
• Communicate UM and appeal determinations to members and providers, including alternative treatment options as needed, to ensure clarity and understanding.
• Participate in cross-functional team meetings and medical management rounds to discuss complex cases and ensure alignment in care planning, contributing to a collaborative and patient-centered approach.

Essential Qualifications

To succeed in this role, you will need:

• A valid New York State Nursing License (RN or LPN), demonstrating your expertise and commitment to the nursing profession.
• 2-5 years of clinical experience in an acute or relevant care setting, providing a strong foundation in patient care and clinical decision-making.
• Demonstrated experience with Appeals and Grievances in a managed care or hospital setting, showcasing your ability to navigate complex appeals processes.
• Prior experience in Utilization Management or Utilization Review (UM/UR), highlighting your understanding of UM principles and practices.
• A High School Diploma or GED, serving as the foundation for your professional development and growth.

Preferred Qualifications

While not mandatory, the following qualifications will enhance your candidacy:

• Experience working in a remote or telecommuting environment, demonstrating your ability to work independently and effectively in a virtual setting.
• Knowledge of regulatory requirements and guidelines governing Appeals and Grievances, as well as UM practices, showcasing your expertise and commitment to compliance.
• Strong analytical and problem-solving skills, enabling you to navigate complex cases and develop effective solutions.
• Excellent communication and interpersonal skills, facilitating collaboration with internal stakeholders and external partners.

Skills and Competencies

To excel in this role, you will need:

• Strong clinical knowledge and judgment, enabling you to make informed decisions and drive positive health outcomes.
• Excellent analytical and problem-solving skills, allowing you to navigate complex cases and develop effective solutions.
• Effective communication and interpersonal skills, facilitating collaboration with internal stakeholders and external partners.
• The ability to work independently and as part of a remote team, demonstrating your self-motivation and commitment to teamwork.
• A patient-centered approach, prioritizing the needs and wellbeing of our members and driving decisions that support their health and satisfaction.

Career Growth Opportunities and Learning Benefits

At our organization, we are committed to supporting the growth and development of our employees. As a Remote NY Appeals Nurse / Utilization Management Specialist, you will have access to:

• Ongoing training and professional development opportunities, enabling you to stay up-to-date with the latest industry trends and best practices.
• Cross-functional training and exposure to various aspects of our organization, broadening your understanding and expertise.
• Opportunities for career advancement and professional growth, supporting your long-term goals and aspirations.

Work Environment and Company Culture

As a remote employee, you will enjoy the flexibility and autonomy of working from home, while remaining connected to our team and culture through regular virtual interactions and collaborations. Our organization values:

• A culture of collaboration and teamwork, fostering a sense of community and shared purpose.
• A commitment to diversity, equity, and inclusion, promoting a welcoming and inclusive environment.
• A focus on employee wellbeing and work-life balance, supporting your overall health and happiness.

Compensation, Perks, and Benefits

We offer a comprehensive benefits package, including:

• A competitive salary up to $105,500+, reflecting your experience and qualifications.
• A generous benefits package, including a Pension Plan, to support your financial security and wellbeing.
• Ongoing training and professional development opportunities, enabling you to grow and develop in your role.

Join Our Team

If you're a skilled and experienced Appeals Nurse / Utilization Management Specialist looking for a remote opportunity with a dynamic and mission-driven organization, we encourage you to apply. Don't miss out on this exciting chance to join our team and contribute to our mission to empower New Yorkers to live their healthiest lives.

Apply now and take the first step towards a rewarding and challenging career with our organization!