CenterWell Pharmacy is seeking an Appeals Nurse to resolve clinical complaints and appeals. You will review medical documentation, interpret data from clinical records, and apply appropriate clinical criteria and policies in line with regulatory requirements. Your work will ensure compliance with TRICARE policies while providing critical education to beneficiaries and providers.
What You'll Do
- Review medical documentation, obtain additional information including physician availability for peer-to-peer review, and forward cases to physician review companies.
- Monitor and follow up for timeliness, review responses and determinations to ensure compliance with TRICARE policy requirements.
- Send cases back for follow-up review and correction if discrepancies are found.
- Review, coordinate, arrange, and maintain Second Level Review/Reconsideration records and patient and provider response letters.
- Provide education to beneficiaries and providers regarding second-level review timeframes, processes, and review determinations.
- Provide education on alternatives for services that may not be approved.
- Maintain knowledge of TRICARE, all HGB policies and procedures, medical necessity review criteria, and privacy requirements.
What We're Looking For
- U.S. Citizenship (Department of Defense contract requirement).
- Successfully receive interim approval for government security clearance (eQIP).
- Cannot be living in Puerto Rico per government contract.
- Active unrestricted RN license.
- 3+ years of clinical RN experience.
- Appeals nursing experience.
- Claims experience.
- Proficient with Microsoft Office products including Word, Excel, and Outlook.
Nice to Have
- Utilization Review/Quality Management experience.
- Experience working with MCG guidelines.
- Working knowledge of ICD-9 or ICD-10, HCPCS, DRG use.
- Experience with TRICARE contracts and/or the military health care delivery system.
- Knowledge of TRICARE policies and programs.
- Bachelor's degree.
Technical Stack
- Microsoft Office (Word, Excel, Outlook)
Benefits & Compensation
- Compensation: $71,100 - $97,800 per year.
- Medical, dental, and vision benefits.
- 401(k) retirement savings plan.
- Time off including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave.
- Short-term and long-term disability.
- Life insurance.
Work Mode
This is a remote position open to candidates across the United States. Candidates cannot reside in Puerto Rico per government contract requirements.
Humana is an equal opportunity employer and does not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status.
