Job Description
The Appeals Nurse will investigate and process medical necessity requests from both members and providers. Reviews the medical record of denied services for medical necessity. For prospective reviews, reviews relevant clinical notations leading up to the request for services. Provides a summary of case for the medical director, and other partners in the health plan care team. Ensures that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements. Serves as a subject matter expert for appeals and grievances. Commit to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Review.
About Peak Health Holdings
Thank you for your interest in working with Peak Health.