Temporary A&G RN

Overview

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com.

In this role you should independently be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained, in alignment with SLAs.

• Investigate and process complex grievances and appeals requests from members and providers

• Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity

• Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards

• Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review

• Document and logs appeal/grievance information on relevant tracking systems

• Generate written correspondence to providers, members, and regulatory entities

• Serve as a subject matter expert for appeals, grievances, and quality of care issues

• Utilize leadership skills

• Assist with or perform other relevant essential functions as required

Qualifications:

• Unrestricted USRN mainland license

• At least 2 years experience in utilization management / review

• Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience an advantage

• Excellent written and verbal communication skills.

• Excellent customer service and interpersonal skills.

• Working knowledge of current industry Microsoft Office Suite PC applications.

• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management

• Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service

• Knowledge of applicable accreditation standards, and local, state, and federal regulations