Utilization Review Nurse I

  • Location

    Nashville, United States

  • Sector:

    Other Area(s)

  • Job type:


  • Contact:

    Leric Arcigal

  • Job ref:


  • Published:

    12 months ago

  • Expiry date:


We will depend on you to communicate some of our most critical information to the correct individuals regarding Medicare appeals and related issues, implications and decisions.The Appeals Reviewer will coordinate and perform all appeal related duties in a Medicare Advantage Plan. These appeals will include requests for decisions regarding denials of medical services as well as Part B and Part D drug. The Appeals Specialist will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.