Appeals Reviewer Veteran Job Description Samples

Results for the star of Appeals Reviewer Veteran

Clinical Appeals Reviewer - West Coast - Telecommute - Veteran's Welcome

Position Description: For those who want to invent the future of health care, here's your opportunity.

We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work. Positions in this function are responsible for providing expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances.

Communicates with appropriate parties issues, implications and decisions. Analyzes and identifies trends for appeals and grievances.This includes senior level positions with education / certification / licensure other than an RN, such as BSW, MSW, DDS, Chiropractor, Physical Therapist, etc. Primary Responsibilities:

Pull medical cases from a queue Research these medical cases and create write up summaries Pass medical case write up summaries on to nurses Receive decisions on whether a case is approved or denied Relay information to the members and document your work Other duties as assigned Required Qualifications: High School Diploma / GED or higher Must live in west coast : California, Oregon, Washington Must be able to use various software Ability to create, copy, edit, send & save utilizing Word, Excel & Outlook 1 years of experience working with Insurance Clinical Appeals Preferred Qualifications: Insurance Claims experience Experience with E&I platform Previous SCIIDRS, IDRS, ECAA,ETS, IQ, systems experience Careers with UnitedHealthcare.

Let's talk about opportunity. Start with a Fortune 14 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better.

Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none.

This is no small opportunity. It's where you can do your life's best work.SM Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Keywords: Appeals, review, grant, approve, decline

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Utilization Review & Appeals RN


Department:Patient & Family Services

Schedule:Full-time 36-40 hours



Job Details:

For more than 100 years, Southern New Hampshire Medical Center has honored our mission: to improve, maintain, and preserve the overall health and well-being of individuals living in the greater Nashua area by providing information, education, and access to exceptional health and medical care services.
We have literally been at the heart of better health for Greater Nashua. Our main downtown campus, a familiar landmark for generations, has grown along with the Gate City. Today, The Medical Center and our affiliated doctors and services extend across much of southern New Hampshire.


The Utilization Review & Appeals RN evaluates medical acuity to assess for appropriate level of care orders and documentation to facilitate insurance coverage.  Works directly with care team to proactively prevent denials and ensure level of care charges are applied accurately per commercial and CMS insurance guidelines.  Appeals medical necessity insurance denials.  Conducts charge reviews to ensure insurance rules are followed. 


*  Bachelor's degree in nursing

*  Three to five years experience in acute care Utilization Review and Appeal writing

*  Experience in use of Interqual, Milliman and other Healthcare acute criteria

*  Excellent writen and verbal communication skills

*  Competent in Microsoft Office and general computer skills

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RN / Appeals Analyst / Utilization Review Nurse

RN / Appeals Analyst

Kelly Healthcare Resources (KHR) has an opportunity for an RN/Appeals Analyst

to come and join our client located in Columbia, SC ! As the RN/Appeals Analyst with a large health insurance provider, you will research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. You will provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines and document decisions within mandated timeframes and in compliance with applicable regulations or standards.

Responsibilities of Job:

  • Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.

  • Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.

  • Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.

  • Performs special projects including reviews of clinical information to identify quality of care issues.


  • Active RN license in South Carolina

  • 3+ years of clinical experience

  • Solid computer skills

  • Excellent attention to detail

  • Ability to work independently


This position is recruited for by a remote Kelly office, not your local Kelly branch. To apply for this opportunity please utilize the Apply Now/Submit Resume button.

You can also submit your resume directly to Patti Vasseur at. Every day, Kelly Healthcare Resources (KHR) specializes in providing highly skilled nursing and allied health professionals within hospitals and other health care facilities, as well as positions in sectors such as insurance, pharmaceutical, health management and education.

In addition to working with the world’s most recognized and trusted name in staffing, Kelly employees can expect:

  • Competitive pay

  • Access to a comprehensive employee benefits package including health, prescription, vision, dental, and life and short-term disability insurance

  • Paid service bonus and holidays

  • Portable 401(k) plans

Why Kelly


With Kelly, you’ll have direct connections to leading healthcare companies providing you with the chance to positively impact quality and delivery of patient care. In a field where innovation and change happen constantly, our connections and opportunities will help you take your career exactly where you want to. We work with 95 of the Fortune 100 companies, and more than 1,200 healthcare hiring managers turn to us each year to access the best talent: people like you.

Let us help advance your healthcare career today.

AboutKelly Services

As a workforce advocate for over 70 years, we are proud to directly employ nearly 500,000 people around the world and have a role in connecting thousands more with work through our global network of talent suppliers and partners. Revenue in 2016 was $5.3 billion. Visit and connect with us on Facebook , LinkedIn and Twitter .

Kelly Services is an equal opportunity employer including, but not limited to, Minorities, Females, Individuals with Disabilities, Protected Veterans, Sexual Orientation, Gender Identity and is committed to employing a diverse workforce. Equal Employment Opportunity is The Law. at

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Claims Appeals Clerk

About us:
Morgan Stephens represents the nation’s top healthcare systems offering the highest compensation and benefits to our top candidates.   We are created and managed by experienced industry professionals in healthcare. As a leading provider of contract, contract to perm, and direct placement recruiting services to healthcare organizations throughout the United States, we have successfully served the needs of our employees and clients by placing thousands of quality healthcare professionals into organizations seeking top talent.
Open Position:
We are seeking and experienced Claims Appeals Clerk
Printing letters
Printing envelopes
Making copies
Creating files for member compliance and appeals
Putting information into the system for documentation purposes
Completing tasks with deadlines
Attention to detail is crucial
Ability to meet deadlines and work under pressure
Strong communication skills
Professional clerical experience/data entry experience
Medical terminology
WPM 35+
Proficiency with Word and Excel 
More Information:

Morgan Stephens ofrecemos reclutadores que hablan Espanol

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Appeals RN – Health Plan

Appeals & Grievances RN – Managed Care
Miami, FL

This is a Full-Time, Benefits Available, CONTRACT-TO-HIRE opportunity, expected to convert into a PERMANENT role after an established timeframe!

Job Summary:

The Quality Improvement Appeals & Grievances Nurse performs all aspects of the Quality Management Program, including the grievances and appeals process, and all related activities, objectives, and analysis. The nurse supports the organization by working to resolve provider payment disputes through advanced and complicated case review of the appropriateness of medical care requiring considerable clinical judgment, independent analysis, and detailed knowledge of managed care and organizational guidelines.  The nurse is responsible for oversight and execution of the grievance and appeals process, which includes coordinating the investigation among departments, analysis of root causes, collaborating with staff to develop corrective action plans, and monitoring corrective action taken. Manages the consolidation of the complaints and grievance activities on a quarterly basis, and prepares monthly, quarterly and annual reports on assigned quality improvement activities.
Your Reward: 
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.
Your Background:
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
Bachelor’s of Science in Nursing (BSN) or related healthcare field is a plus.
At least 2-5 years acute care clinical nursing experience is required.
Around 2-4 years of recent experience at a health plan or other managed care organization (HMO/TPA/IPA/etc).
Roughly 1-2 years of experience handling Denials and/or Appeals and/or Grievances.  Case Management and/or Utilization Review experience will be considered in lieu of direct Appeals/Denials experience.
Direct experience with guidelines for Medicaid/Medicare and related state programs is required.
Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Your Duties:
Facilitates continuous improvement in the health plan delegated networks by providing individualized case review and processing.  Performs clinical review related to Grievances, Appeals, Quality Referrals and Occurrences by identifying the issues of the case, ordering and collecting needed documents or records, reviewing the case documents, completing a case summary, and either leveling or reviewing the case with the Medical Director or CMO as appropriate.  Coordinates and submits results of focused review studies, medical record audits and HEDIS results as appropriate. 
Acts in the capacity of member advocate addressing member or provider concerns, maintaining absolute file integrity with regards to content, location, and confidentiality.  Conducts clinical review and evaluation of member and provider complaints, grievances and appeals using considerable clinical judgment, evidence based standards, independent analysis, knowledge of operational policies, clinical guidelines, plan benefit structures and regulatory requirements to determine the appropriateness of care provided.  Reviews, triages and prioritizes cases to meet required turnaround times.  Ensures that appeals and grievances are categorized and processed within appropriate state and federal time frames. Interacts with external partners, including providers, medical groups, IPAs and other external vendors to obtain additional information to resolve the member's case.   Interaction includes preparing for and participating in regulatory site visits.  Performs research and analyzes complex issues.  Identifies potential quality issues and initiates investigations, processing any substantiated quality of care issues.  Summarizes cases including articulation of member's perception, initial denial determination and notification, analysis of medical records, and appropriate application of all applicable policies, guidelines, benefit plans and laws, rules and regulations. 
Maintains strict compliance with federal, state and NCQA requirements and guidelines.  Participates in and coordinates Quality Management committee activities by assisting with development of the agenda, providing the assigned meeting documents, and presenting reports.  Provides complete and accurate documentation of work performed by entering data into specified databases or forms as instructed and reporting any required metrics.  Participates in the Quality Management process by identifying problems, examining solutions options, implementing action plans and by coordinating, facilitating and/or participating in inter and intradepartmental quality initiatives and work groups.

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Mgr Grievances & Appeals

Job ID 52106

Category: Other

Location: Newark, NJ

Experience: 3 to 5 years

Posted: 8/8/2017

Education: See Requirements

Job Description


We are currently seeking a dynamic Manager, Denials and Appeals to join our team in Newark, NJ.The Denials and Appeals Manager will have overall responsibility to achieve operational business goals as is related to managing denials and appeals according to State, Federal laws, regulations and mandates and NCQA/URAC accreditation. The Manager builds customer loyalty by developing, motivating and retaining a committed staff of Appeal Coordinators, who deliver high quality, cost effective member and provider services.

Position Responsibilities:

  • Manage clinical appeals; administrative and executive complaint resolution; legal and regulatory inquiry resolution

  • Maintain policies and procedures, SOPs, process flows and correspondence templates; support internal and external audits and the coordination of regulatory and client audit related activities.

  • Assure compliance with all state and federal laws, regulatory requirements, accrediting agencies (NCQA and URAC) as well as Beacon Health Options corporate policies and procedures.

  • Responsible for meeting and exceeding targeted performance guarantees (PG) stipulated within client agreement

  • Accountable for management of departmental inventory and work allocation assignments to staff

  • Generate and delivery client reporting related to key performance indicators, internal and external production reports, and quality management reports

  • Manage production and quality standards among Coordinators and Quality Specialist

  • Provide daily oversight to the supervision of personnel, which includes work allocations, schedules, ensure employee education and training including building employee knowledge, skills and capabilities required to perform in their job function that will contribute to improved performance

  • Manage and adjust quality audit programs to support the department's objectives, including corrective action plans.

  • Make recommendations for personnel actions and approve motivational plans and/or programs for individual or team performance

  • Additional management responsibilities or projects assigned by leadership

Position Requirements:

Education: Bachelor's degree in Business Management, Allied Behavioral Health, Healthcare Management or related degree; Master's preferred

Licensure: MSW, MFT, LPC, RN preferred

Relevant Work Experience: A minimum of 3-5 years' general operations and appeal management experience in the health care industry

Knowledge, Skills & Abilities:

  • Extensive knowledge and understanding of business systems that include client service and mainframe applications as well as computer literacy and management information systems are required.

  • Knowledge of and ability to understand medical terminology and health insurance regulations

  • Ability to research and solve problems with minimal supervision


Click below on"Apply for this Position"to create a profile and apply for the position. Beacon Health Optionsis proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled




Job Requirements


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Medical Insurance Appeals Specialist

Job Description

Seeking experienced part time (25-29 hrs/wk) insurance appeals specialist for busy surgeon's office in Centerville. Must know CPT and ICD9-10 coding.  Must be a fast leaner, self motivated team player with pleasant attitude and professional appearance. Please send resume for prompt consideration.

Company Description

Busy 3 physician office with Medicare approved AAAA Surgery Center on site. All physicians are Board Certified in Plastic Surgery.

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Court Criminal Appeals Clerk - Administrative Assistant III

Multiple positions may be filled from this announcement.Position is part of the Case Processing Section of the Criminal Division of the Circuit Court. Under general supervision performs a wide range of duties in processing criminal cases.

Must possess good time management, have strong attention to detail and exceptional customer service skills.

All criminal processing transactions must be accurate and performed in a timely manner in order to meet mandated deadlines. Duties include but are not limited to:

Responsible for the preparation of various case types within the Criminal Division Routinely interact with judges, Commonwealth's Attorneys, the Districts Courts, the sheriff's department and defense attorneys. Performs a variety of functions as required by specific documents, cases, or judgments using the court case management system. Processes felony cases, misdemeanor and traffic infraction appeals, juvenile appeals, court orders, and search warrants.

Functions as a customer service representative for the Criminal Division on the phone, in person, and through correspondence. Maintains, initiates, updates, and manages case files, both electronic and paper for use by the public, staff, judges, lawyers, and other county and state agencies. Performs related duties as required

This is an entry level position and salary offer for the position will not exceed the mid-point of the advertised salary range.

Employment Standards

MINIMUM QUALIFICATIONS:Any combination of education, experience and training equivalent to high school graduation and two years of experience providing administrative support in the assigned functional area(s).NECESSARY SPECIAL REQUIREMENTS:The appointee to this position will be required to complete a criminal background check to the satisfaction of the employer.PREFERRED QUALIFICATIONS: Associate's degree Three to four years' of experience performing administrative work.

Three to four years' of experience in a court or legal environment. Exceptional attention to detail, exercise tact, discretion, initiative, and independent judgment. Excellent communication and customer service skills.

Ability to perform multiple complex tasks simultaneously in a high-volume environment as well as handle sensitive information while maintaining confidentiality. Must be able to work independently and in a team environment. Ability to develop and monitor Excel spreadsheets to track information and statistics.

Experience in the use of Microsoft Office computer software, especially Word, Outlook, and Excel.PHYSICAL REQUIREMENTS:Requires ability to lift boxes, file and push a cart weighing up to 20 pounds. Ability to input and retrieve data from a computer. Must be able to type at least 30 wpm due to high volume of legal documents.

Physical requirements can be performed with or without reasonable accommodations.SELECTION PROCEDURE:Panel interview. As part of the interview process you may have to complete a written exercise, that is a writing sample. You will be provided with a short question/subject and are required to type your response within 30 minutes on the computer.

It is the policy of Fairfax County Government to prohibit discrimination on the basis of race, sex, color, national origin, religion, age, veteran status, political affiliation, genetics, or disability in the recruitment, selection, and hiring of its workforce.Reasonable accommodations are available to persons with disabilities during application and/or interview processes per the Americans with Disabilities Act. Contact 703-324-4900 for assistance. TTY 711. EEO/AA/TTY.

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Appeals & Grievance Coordinator

Grievances and Appeals Coordinators serve as a single point of contact to provide support and advocacy to health plan members for resolution of grievances. Basic Qualifications:

Minimum of one year of recent experience as an Appeals and Grievances Coordinator. Strong computer and telephone multitasking skills including: the ability to effectively search for and type information on the computer, navigate through multiple windows and screens quickly, and inputting information accurately while keeping pace with the call Requires excellent verbal and written communication skills Excellent analytical and problem-solving skills with the ability to make independent decisions. Must have strong technical skills (Microsoft Windows, keyboarding skills, strong systems aptitude, etc.) Ability to remain focused and productive each day though tasks may be repetitive Responsibilities:

Receives member complaints via telephone and/or written correspondence then categorizes the member complaint as a grievance, appeal, or inquiry as defined by CMS, if it is for a Medicare/Medicaid claim Coordinate the overall grievance resolution process by evaluating and resolving oral and/or written complaints from members in compliance with federal, state, and organizational grievance procedure guidelines Communicate decisions to members verbally or through written correspondence to close the grievance in a timely and accurate manner Preferred Qualifcations: Previous successful work at home experience

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Appeals Coordinator

Job Description: Reviews and evaluates external denials for medical necessity.

Coordinates and monitors the preventive denial and appeals process. Education: Valid nursing license in the State of Maryland. BSN preferred.

Certified Professional in Utilization Review, Case Management, and Health Care Quality preferred. Experience: Five years clinical experience required; Case Management, Quality Management, or Discharge Planning desirable. Five years in Utilization management and appeals decision and writing.

Skills: Excellent verbal and written communication. Experience with personal computer and word processing software preferred. Physical Requirements:

Visual acuity; manual dexterity and physical mobility; hear and orally communicate. Light physical effort (lift/carry up to 10 lbs.). Mostly sedentary work. Working Conditions: Normal working conditions FeaturedJob0

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