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Healthcare Foundation of Northern Lake County

Grayslake, Illinois

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Reno, Nevada

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Loveland, Colorado

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Duke University Health System

RALEIGH, North Carolina

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Fresno, California

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AdventHealth

Wesley Chapel, Florida

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Mechanicsburg, Pennsylvania

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Duke University Health System

Durham, North Carolina

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AdventHealth

Winter Park, Florida

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Mental Health America

Alexandria, Virginia

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Wesley Chapel, Florida

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Alexandria, Virginia

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Wesley Chapel, Florida

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Mental Health America

Alexandria, Virginia

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Manchester, New Hampshire

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Columbus, Ohio

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Bolingbrook, Illinois

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San Francisco, California

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Bellevue, Washington

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Vanderbilt Health

Nashville, Tennessee

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Boise, Idaho

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La Jolla, California

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Appeals Nurse RN - Community Health Choice
The Appeals Nurse RN will assist the Appeals Manager and the Medical Director in the review of medical records submitted for appeals by providers due to adverse determination. Utilize Milliman Care Guidelines and Medical Affairs departmental policies for medical necessity and level of care determination. Utilize 3M Coding and reimbursement guideline for DRG assignment. Provides written response of the outcome of the appeals finding to the appealing provider. Assists in the ongoing development and maintenance of a database for tracking, trending and reporting appeals cases. Qualifications Registered Nurse, current Texas License One year of experience utilizing evidence based criteria in medical reviews in Utilization Management or Appeals required.


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