Clinical - Appeals Nurse - 210989

Job Summary
Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

Education/Experience: LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.

License/Certification: RN or LPN license.

For Fidelis Care only: NYS RN license required.

Responsibilities
• Review clinical data to determine claim payment based on company policies and
• National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
• Gather and prepare case information for Administrative Law Hearings
• Maintain appeals process within the 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.

EEO:

“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”

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Story Behind the Need
What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?		Review medical records for medical necessity, using approved criteria application, to make recommendations for MD on appeal medical necessity reviews. Current Clinical staff OT in 2026 5224 hrs., reduction in cost if we bring in contractors $6k a month. With reduction of 2 clinical staff during VSP but CMS membership going away in 2027, this contractor solution will bridge the gap while work and volumes settle. Remote team that stays engaged via Teams chats and monthly meetings. Clinical team works closely with both admin team and medical directors’ team. No other upcoming hiring needs are currently anticipated.
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?			Receive assignments electronically via company applications and excel sheets, emails are also sometimes used for case communication. Review appeal requests, medical records, and apply applicable medical necessity criteria. Write up the appeal clinical review and forward to MD for review and final determination. Receive the case back post MD review for clinical closure and route to coordinator for case closure. 4-8 complete cases per day. Ability to work remotely and self-directed to keep oneself at pace. Able to use clinical knowledge and experience to visualize the appeal request and get better understanding of clinical picture.
Candidate Requirements
Education/Certification	Required: Nursing certification/degree				Preferred:
Licensure	Required: RN or LPN FL Licensure Required				Preferred: N/A
Years of experience required: At least 3 years in a clinical setting followed by at least 1 year experience in managed care/ utilization management setting such as prior authorization clinical reviewer; appeals clinical reviewer a plus/preferred. Disqualifiers: Less than 1 year or no managed care / utilization management experience. Additional qualities to look for: Experience using InterQual criteria application, Also, candidate who in addition to clinical physical health experience has experience in clinical mental health care.
Top 3 must-have hard skills stack-ranked by importance			1	Clinical utilization management experience – clinical reviews
			2	InterQual criteria application
			3	Able to work independently
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations			Projected Manager Candidate Review Date:			1-2 days post shortlisting
			Type of Interviews:			Teams
			Required Testing or Assessment (by Vendor):			None
Next Steps
Do you have any upcoming PTO?			No
Colleagues to cc/delegate			Dagmar Hernandez-Molina for interviews; timecards Mary Beth Anderson for any manager approvals needed; aside from timecards