Appeals Review Nurse

Posted about 2 months agoViewed

💎 Seniority level: Middle, 1+ year of utilization review experience, 1+ years of clinical experience, 1+ years experience with medical decision support tools

📍 Location: Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Washington D.C.

💸 Salary: 35.0 - 45.95 USD per hour

🔍 Industry: Health Insurance

🏢 Company: Oscar Health👥 1001-5000💰 $140,000,000 Private about 4 years ago🫂 Last layoff over 4 years agoHealth Insurance InsurTech Insurance Health Care

⏳ Experience: 1+ year of utilization review experience, 1+ years of clinical experience, 1+ years experience with medical decision support tools

🪄 Skills: Data AnalysisCommunication SkillsAnalytical SkillsCollaborationProblem SolvingAttention to detailOrganizational skillsTime ManagementWritten communication

Requirements:

Active, unrestricted RN licensure from the United States in specified state or active compact multistate unrestricted RN license.
Associate Degree in Nursing or graduate of an accredited School of Nursing, or successful completion of a Diploma Program in Practical Nursing of an accredited School of Nursing.
Ability to obtain additional state licenses as needed.
1+ year of utilization review experience in a managed care setting.
1+ years of clinical experience, including at least 1+ year in an acute care setting.
1+ years experience with medical decision support tools such as Interqual, MCG, NCCN.

Responsibilities:

Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines.
Obtain necessary information via telephone and fax to assess a member's clinical condition and apply appropriate evidence-based guidelines.
Meet required decision-making SLAs.
Refer members for further care engagement when needed.
Ensure compliance with all applicable laws and regulations.
Perform other duties as assigned.

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