Appeals and Grievances - RN, Senior

The Appeals and Grievances RN Senior will perform clinical review of member-initiated appeals or appeals initiated on behalf of members from an authorized representative, utilizing Milliman Care Guidelines, Member Handbook or Evidence of Coverage, and other nationally recognized professional guidelines.

Requirements

• Accurate and timely clinical review of member-initiated appeals or appeals initiated on behalf of members
• Utilize Milliman Care Guidelines, Member Handbook or Evidence of Coverage, and other nationally recognized professional guidelines
• Perform first level appeal reviews for members
• Review both inpatient and outpatient member appeals for benefits, medical necessity, coding accuracy and medical policy compliance