RN Provider Appeals Coordinator (Hybrid) - Medical Appeals - 40 Hours Weekly - Day Shift - HAP Health Alliance Plan
🔍 Troy, Michigan
RN PROVIDER APPEALS COORDINATOR - MEDICAL APPEALS - 40 HOURS WEEKLY - DAY SHIFT
Full Time Benefit Eligible
Schedule: Monday through Friday, 8:00AM to 4:30PM. This position is primarily remote with the possibility of in person meetings and trainings periodically at our Troy headquarters.
GENERAL SUMMARY:
Unit Description:
Health Alliance Plan (HAP) is looking to grow our Medical Appeals Team with an experienced Registered Nurse! We are a team of Registered Nurses (3 and counting) and Utilization Review Coordinators (4) that review appeals for medical necessity using established medical criteria, readmission appeals, administrative appeals for provider and member appeals in partnership with our Medical Directors. If you have experience with prior authorizations, are known for your attention to detail, and are considering a nursing career away from bedside care, we want to meet you!
- Responsible for investigating Provider Appeal requests and Code Review inquiries for all Utilization Management divisions, including delegated entities.
- Summarize outcome of investigation for decision by Medical.
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and duties. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described above.
EDUCATION/EXPERIENCE REQUIRED:
- Nursing Diploma or equivalent.
- Bachelor's Degree in Health Care or related field preferred.
- Minimum of two (2) years of experience in clinical management of patients in an inpatient or ambulatory setting, or at least three (3) years of experience in Utilization Management or Case Management.
- Demonstrated knowledge of the InterQual® or Milliman Care Guidelines® criteria preferred.
- Knowledge of Medicare, Medicaid and NCQA guidelines and use of CMS website for research preferred.
- Knowledge of use of Microsoft Office Suite.
- Knowledge of ICD-10 and CPT coding, medical necessity criteria and medical terminology.
- Must work effectively with persons of varying position levels and diverse interests to reach consensus on resolution of problems.
- Excellent written and verbal communication skills.
- Must be able to interact professionally with physicians, members, and other internal and external customers.
- Ability to prioritize and coordinate workflow.
- Ability to manage multiple tasks simultaneously.
- Ability to work independently with limited supervision.
- Must have excellent organizational skills.
- Must have excellent interpersonal and telephone skills.
- Ability to make decisions and initiate appropriate actions based on analysis of data.
- Ability to participate in problem identification and resolution with team members.
- Knowledge of inpatient and outpatient procedures and practices.
- Knowledge of NCQA, CMS, DOL, ERISA and other regulatory body rule preferred.
- Computer skills including Windows and Microsoft Word. Excel and Access preferred.
CERTIFICATIONS/LICENSURES REQUIRED:
- Registered Nurse (RN) with current Michigan licensure.
Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers.
Benefits
The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.