RN, Registered Nurse Appeals

About the role

The Registered Nurse (RN) – Appeals is responsible for managing all clinical appeal requests according to Quantum Health’s defined process for the receipt, logging, preparing for review, evaluation and response. This critical clinical subject matter expert works to increase the consistency, efficiency and appropriateness of responses for all appeal service requests.

Quantum Health nurses must be willing and able to obtain and maintain nursing licensure in multiple states, as required by the business. All application and filing fees will be paid by Quantum Health.

This position is located at our Dublin, OH campus with hybrid flexibility.

• Review and process all appeal requests;
  Prepare requests for review by researching Specific Plan Detail (SPD) provisions, applicable criteria, analyzing the basis for appeal and preparing a written summary of each case.
• Assure timely processing and response to appeal requests.
• Communicate with member, provider, facility, and all internal work groups regarding appeal requests/outcomes.
• Collaborate with Medical Directors, Physician reviewers, External Medical Directors, and Independent Review Organization (IRO) to process all requests requiring physician review. Identify care coordination and case management opportunities.
• Maintain a working knowledge of all clinical processes and workflows, employer benefit plans and related documentation.
• Participate in educational training with clinical staff regarding the appeal process;
  Partner with the clinical operations managers to identify coaching opportunities for the clinical services team, identify trends, and improve processes.
• Assist pre-certification team as needed with medical reviews, assist with pre-certification training, serve as enhanced pre-certification trainer for new nurses, provide coaching to care coordination nurses on appeal cases, etc.
• All other duties as assigned.

• Licensure: Active and current license in good standing as a Registered Nurse (RN) in the State of Ohio required.
• Education: Bachelor of Science in Nursing (BSN) degree in nursing preferred
• 3+ years of clinical experience with direct patient care in a hospital setting required.
• Experience working in the clinical review and/or appeal process, ideally in a health insurance setting preferred.
• Strong administrative/technical skills;
  Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
• Excellent verbal and written communication skills. Comfortable communicating with members and providers via phone regularly throughout the day.
• Trustworthy and accountable behavior, capable of viewing and maintaining confidential personal information daily.
• Ability to communicate effectively with members and providers in implementing clinical services;
  Translate complex clinical concepts for non-clinical audiences.
• Strong administrative/technical skills;
  Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
• Trustworthy and accountable behavior, capable of viewing and maintaining confidential information daily.