Medicare Appeals RN

Job description

Job Summary Appeals & Post Service Review RN role is centered on the daily case review for appeals from members, members' beneficiary representatives, and providers in order to meet timeliness & documentation compliance metrics. In addition, the role also is responsible for post service review and clinical provider appeals. Facilitates final determination based on findings and procedures within strict timelines established by regulatory requirements. Authors final appropriate statement supporting final determination based on appropriate criteria or medical director determination. Essential Functions: The essential functions listed represent the major duties of this role, additional duties may be assigned. Reviews and researches appeals to reach timely, appropriate determination. Reviews and researches member and provider appeals and their medical documentation, abstracts pertinent data into the documentation system, and reviews with Medical Director to reach a final determination. Processes Post Service reviews, abstracts pertinent data into the documentation system, reviews with Medical Director, as appropriate, to reach determination. Accesses Legacy or Diamond to review how clai...