RN Provider Appeals Coordinator (Hybrid) - Health Alliance Plan - 40 Hours Weekly - Day Shift
Full Time Benefit Eligible

Schedule: Monday through Friday, 8:30AM to 5PM, Hybrid
GENERAL SUMMARY:

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 Director.

PRINCIPLE DUTIES AND RESPONSIBILITIES:
1. Investigate and prepare case summary for Provider Appeal and Code Review
inquiries based on network, product, medical criteria, regulatory requirements, and
business rules.
2. Present appeal case summary to Medical Directors for review and decision.
3. Review and make decisions for appeal requests that include emergency and elective
admissions, elective procedures, DME, Home Care, Hospice and Home Infusion.
4. Review appeal request for appropriateness of se...