Appeals Nurse - Behavioral Health
Job Title: Medical Necessity Appeals and Denials Facilitator
Job Description
This role involves facilitating medical necessity appeals and denials, managing notification letters for denials, and reviewing clinical information to determine if medical necessity criteria are met.
Responsibilities
- Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (NCQA) guidelines.
- Overturn denied claims, uphold denials, and submit cases to the Medical Director for review.
- Prepare case reviews for the Medical Director in cases where criteria are not met based on additional clinical information received.
- Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines.
- Create system authorization events for overturned denial decisions.
- Request additional information from providers to facilitate timely appeals resolution.
- Gather and prepare case information for Administrative Law Hearings.
- Maintain appeals process within prescribed NCQA timeframes and appeals turnaround database.
- Assist the Medical Director with revising, updating, and/or creating new policies to satisfy NCQA and contractual requirements.
Essential Skills
- LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience.
- Proficiency with Microsoft Office applications.
- Experience with utilization or appeals review.
- Knowledge of InterQual criteria.
- RN or LPN license.
Additional Skills & Qualifications
- NYS RN license required.
- Familiarity with quality improvement and HEDIS Abstractions.
- Experience with Medicare/Medicaid.
Work Environment
Work with a team dedicated to ensuring compliance with NCQA guidelines and contractual requirements. Utilize modern office technologies, including Microsoft Office applications. Collaborate closely with a Medical Director to enhance policy and procedural adherence. The work involves maintaining a detailed and structured approach to appeals processing within a dynamic healthcare setting. Job Type & Location This is a Contract position based out of New York, NY. Pay And Benefits The pay range for this position is $36.00 - $40.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits Available For This Temporary Role May Include The Following
- Medical, dental & vision
- Critical Illness, Accident, and Hospital
- 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
- Life Insurance (Voluntary Life & AD&D for the employee and dependents)
- Short and long-term disability
- Health Spending Account (HSA)
- Transportation benefits
- Employee Assistance Program
- Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type This is a fully remote position. Application Deadline This position is anticipated to close on Dec 1, 2025. About Actalent Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [email protected] for other accommodation options. Apply tot his job Apply To this Job