Case Manager (RN) / Clinical Nurse
Horizon Healthcare Staffing is searching for a clinical nurse for one of our clients in New York, NY.
- This is a temp to hire position.
- Monday through Friday
The Clinical Nurse is responsible for investigating and processing comprehensive and complex grievances and appeals requests from members and providers, coding justifications, and provider disputes. This position identifies through clinical review any system or processing issues that resulted in failure to provide appropriate care to members, failure to meet service expectations, billing concerns, and provider disputes.
- Conducts investigations and reviews of member and provider medical necessity grievances and appeals;
- Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity;
- Extrapolates and summarizes medical information for Medical Director, consultants or other review;
- Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines;
- Ensures that appeals, grievances and disputes are resolved timely to meet regulatory requirements;
- Apply expedited criteria to recommend the appropriateness of urgent requests;
- Documents and logs appeal/grievance/dispute information on relevant tracking systems;
- Generates written correspondence to providers, members and regulatory entities;
- Interact with members, providers and/or other staff to ensure resolution of plan recommendations;
- Recognize potential quality of care concerns and refer to the Medical Director for review;
- Serves as a subject matter expert for appeals/grievances/disputes/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues;
- Support to drive resolution of issues that may arise;
- Be familiar with business / industry concepts and terminology as pertains to appeals, grievances and claims processing;
- Identify requests for escalation / complaints and escalate accordingly;
- Research complex issues across multiple databases and work with support resources to resolve inquiry;
- Active NYS RN License
- Managed care experience needed
- Prefer some experience with Medicaid and/or Medicare Advantage