Virginia Premier Health Plan RN, Appeal Nurse in Glen Allen, Virginia
Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
If this sounds like you, read on!
The Appeal Nurse’s will manage member andpractitionerappeal activities, to ensure that service standards are met, and operations are consistent with the health plan policies, as well as the policies of the regulatory agencies. The incumbent will participate in managing the organization’s State Fair Hearing review for our Medicaid population, including handling expedited and standard requests and providing oversight of program resolution and assist in processing of the cases. Ensures State Fair Hearing requests are processed in accordance with regulations, compliance standards and policy and procedures. Investigation and preparation of case summaries and resolution statements based on clinical information, benefits, applicable regulations related to member dispute of decisions. The Appeal Nurse shall also be responsible for serving as the plan’s subject matter expert and liaison for the members and practitioners related to all appeals activities. The incumbent is also responsible for creating monthly, quarterly and annual reports pursuant to the Department of Medical Assistance Services (DMAS), National Committee for Quality Assurance (NCQA), regulatory requirements and agencies.
Responds to member and practitioner appeals with minimal direction
Investigates and resolves member and practitioner appeals within plan regulatory and accreditation timeframes
Prepares, attends and presents appeals documentation for plan, regulatory hearings and/or during audits
Prepares appeals written documentation responses
Provides timely assistance to members and practitioners in filing formal appeals and ensures that members are advised of their appeal rights
Works collaboratively, coordinates, communicates and integrates recommendations from impacted organizational departments and/or Senior Level Executives and other designated staff, as approved and required
Generates reports with trend analysis and recommendations for quality improvement
Communicates detailed account of risk management issues to the Manager within the specified timeframe
Assists with training, in-services and quality audits as a result of plan, regulatory or accreditation requirements
Acts as an appeal Subject Matter Expert (SME) in the absence of the Medicare or MedicaidGrievances & Appeals managers
Attends Member Advisory Committee (MAC) and Provider Advisory Committee (PAC) meetings
MINIMUM EDUCATION REQUIREMENTS
- Current, active, unrestricted nursing license
SPECIAL KNOWLEDGE AND/OR SKILLS
Strong interpersonal skills
Exceptional interpersonal and problem solving skills
Positive and approachable demeanor
Strong written and oral communication skills
Proficient in MS Office applications (Word, Excel, Power Point)
Customer service experience in a health care office environment
Ability to succinctly deliver pertinent information to a variety of audiences to include members, practitioners, organizational executives, attorneys and/or accreditation and regulatory auditors
Working knowledge of computers and word processing programs
Experience working with low income, indigent and/or disadvantaged populations
Requires extensive sitting with periodic standing and walking.
Requires significant use of personal computer, phone and general office equipment.
Needs adequate visual acuity, ability to grasp and handle objects.
Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
May require off-site travel
All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE
Our mission is to inspire healthy living within the communities we serve!
Job ID 2018-4962
As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.