Clinical Appeal Nurse
BHPS provides Utilization Management (UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in a quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager.
Note: This job description is not intended to be an exhaustive list of duties. Responsibilities may evolve or change at any time, with or without notice. This is a remote role.
Primary Responsibilities
- Independently review and analyze pre and post service medical necessity and benefit appeals, post-service clinical claim disputes, and quality of care grievances.
- Utilize member-specific benefit information, nationally recognized clinical criteria, and internal policies and procedures across multiple care disciplines, including, but not limited to, Inpatient Acute, Post Acute, Outpatient, Specialty Pharmaceutical, and Durable Medical Equipment
- Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs) for timely and accurate decisions
- Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and accreditation requirements from intake through case closure.
- Prioritize caseload and other assigned duties to meet clinical accuracy expectations and turnaround time requirements
- Accurately enter case details in medical management platform
- Collaborate with team members and other departments to achieve exceptional results and drive continuous improvement
- Active and unrestricted RN or LPN license; must maintain licensure throughout employment
- Minimum of 5 years’ experience in Clinical Appeals and Grievances within a managed care or payor setting
- Minimum of 5 years’ clinical experience across various care settings (Inpatient Acute, SNF/LTAC/ARU, Outpatient, DME, Complex Care)
- Strong understanding of UM/Appeals regulatory guidelines including URAC, NCQA, and ERISA
- Proficiency in Clinical Appeals, Utilization Review, and Grievance processes including benefit interpretation, contract language, and medical policy application
- Excellent written and verbal communication skills
- Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
- Ability to work independently with exceptional accountability
- Adaptability to a fast-paced and evolving environment.
- Preferred experience in a Third-Party Administrator (TPA) setting
- Preferred coding certification
About
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.
Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.
Come be a part of the Brightest Ideas in Healthcare™.
Company Mission
Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.
Company Vision
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
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