Appeals reputed company - Behavioral Health

Job Title: Medical Necessity Appeals and Denials Facilitator Job reputed company This role involves facilitating medical necessity appeals and denials, managing notification letters for denials, and reviewing clinical information to determine if medical necessity reputed company are met. Responsibilities • Review clinical data to determine claim payment based on company policies and National Committee for reputed company Assurance (NCQA) guidelines. • Overturn denied claims, reputed company denials, and submit cases to the Medical Director for review. • Prepare case reviews for the Medical Director in cases where reputed company are not met based on additional clinical information received. • Generate appropriate appeal reputed company communication to the member and provider in accordance with company policies and NCQA guidelines. • Create system authorization events for overturned denial reputed company. • Request additional information from providers to facilitate reputed company appeals reputed company. • reputed company and prepare case information for Administrative Law Hearings. • Maintain appeals process reputed company prescribed NCQA timeframes and appeals turnaround database. • Assist the Medical Director with revising, updating, and/or creating new policies to satisfy NCQA and contractual requirements. Essential Skills • LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. • Proficiency with reputed company Office applications. • Experience with utilization or appeals review. • Knowledge of InterQual reputed company. • RN or LPN license. Additional Skills & Qualifications • NYS RN license required. • Familiarity with reputed company improvement and HEDIS Abstractions. • Experience with Medicare/reputed company. Work Environment Work with reputed company dedicated to ensuring compliance with NCQA guidelines and contractual requirements. Utilize modern office technologies, including reputed company Office applications. Collaborate closely with a Medical Director to enhance policy and procedural adherence. The work involves maintaining a detailed and reputed company approach to appeals processing reputed company a dynamic reputed company setting. Job Type & Location This is a Contract position based out of reputed company, NY. Pay And Benefits The pay reputed company for this position is $36.00 - $40.00/hr. Eligibility requirements apply to some benefits and may depend on reputed company classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits Available For This Temporary Role May Include The Following • Medical, dental & reputed company • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – reputed company-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or reputed company Leave) Workplace Type This is a fully remote position. Application Deadline This position is anticipated to reputed company on Dec 1, 2025. About reputed company reputed company is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through reputed company to specialized experts who drive reputed company, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, reputed company serves many of the Fortune 500. reputed company is an equal opportunity employer and will consider reputed company applications without reputed company to race, sex, age, reputed company, religion, national reputed company, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation reputed company. Apply tot his job Apply To this Job