Quantum Health
  • - Clinical Services
  • Columbus, OH, USA
  • Full Time

Job Title: Appeal Nurse

Business Unit: Clinical Services

Reports to: Clinical Manager

Quantum Health is a fast growing company delivering better healthcare while lowering healthcare costs. If you are passionate about helping people and want to launch a career at one of the Best Places to Work in Columbus and the USA, now is your time to join our winning culture! We are looking for a qualified Appeal Nurses. 

Description: The Appeal Nurse is responsible for the management of all clinical appeal requests according to QH's defined process for the receipt, logging, preparing for review, evaluation and response. This position will work to increase the consistency, efficiency and appropriateness of response for all appeal service requests.  

 

Roles and Tasks:

  • Review and process all appeal requests
  • Prepare requests for review by researching 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
  • Maintain a working knowledge of all clinical processes and workflows
  • Maintain a working knowledge of all employer benefit plans and related documentation
  • Work with Medical Director/Physician reviewer/External Medical Directors to process all requests requiring physician review
  • Identify care coordination and case management opportunities (Complex, High Cost, Transplant)
  • Participate in educational training with clinical staff regarding the appeal process
  • Work with the clinical operations managers to identify coaching opportunities for the clinical services team

Skills and Qualifications:

  • Current unrestricted license as a Registered Nurse in the state of Ohio
  • Bachelor's degree in nursing or a closely related field or equivalent clinical experience
  • Minimum of 3 years of nursing experience
  • Strong working knowledge of health insurance coverage and appeal processes
  • Preference for experience in the management of the appeal process in a health insurance environment
  • Strong working knowledge URAC/DOL guidelines
  • Strong working knowledge of the clinical review process/appeal process
  • Excellent critical thinking skills
  • Strong interpersonal skills
  • Excellent verbal and written communication skills
  • Self-directed, organized with excellent time management skills
  • Computer literacy
  • All job offers are contingent on successful completion of a background and reference check

Join our Quantum culture which rewards hard work while having fun! 

Benefits include:

  • Earn up to 120 hours (15 days) of Paid Time off each year
  • Medical/dental/vision insurance including domestic partner benefits
  • 401(k)
  • On-site amenities include fitness facility, pool table, serenity room
  • We offer a casual dress environment
  • Free beverages, snacks and ALWAYS fresh-popped popcorn

Want to join our winning culture?  Then apply today at http://www.quantum-health.com/careers/

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