Appeals & Grievances Review Nurse

WellCare Health Plans, Inc. (NYSE:WCG) a Fortune 1000 company, is the nation?s leading provider of government health insurance products dedicated to government-sponsored health plans such as Medicare, Medicaid, State Children?s Health Insurance Programs, Medicare Prescription Drug Plans and others. Founded in 1985, our team of 2,500 associates and over 20,000 physician partners serve 1.4 million members across the U. S. Our company headquarters are based in Tampa, FL. For more information about WellCare, please visit the Company?s website at www.wellcare.com.

 

We are looking to add a Review Nurse to our Appeals & Grievances team.  If you truly believe in teamwork, consistently demonstrate a high level of integrity and want to be a part of a dynamic, growing organization, then this may be the opportunity for you.

 

Job Summary:

Position is responsible for evaluating and coordinating a member?s plan of treatment with the physician and monitor clinical progress. 

 

Essential Functions:Interpret a variety of instructions furnished in written and oral form.Apply regulatory requirements and accreditation standards to all review activity and reporting. Apply accepted criteria to review process and utilizes the parameters.Ensure quality customer service and maintain confidentiality.Collect information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation.  Input review data into systems.Retrieve and distribute faxes. Prepare and submit projects, reports or assignments as needed to meet department initiatives and/or objectives. Assist in evaluating process improvements.

 

Additional Duties:

Perform other duties as assigned.

 

Supervision Received/Exercised:

General supervision through periodic checks on progress and methodology.

 

Scope of Decisions:

Decisions require technical expertise but are often bound by policy, procedure or past practice.

 

Knowledge, Skills, Abilities Required:RN licensed in the applicable state. College degree or a minimum of three years relevant work experience.Demonstrated knowledge of medical terminology, CPT and ICD9 coding.Managed care experience preferred. Prior Appeals and Grievances experience preferred.

 

Communication and Numeric Skills:Oral and written communication skills sufficient to answer clearly a variety of questions from people both within and outside of the organization. Demonstrated negotiation skills.

 

Computer Skills:Knowledge of email systems such a Microsoft Outlook sufficient to communicate with both internal and external contacts.Knowledge of Sidewinder and Diamond system sufficient to perform review and data entry preferred.  Knowledge of Word sufficient to create simple documents such as memos and reports.Knowledge of Excel sufficient to enter data into spreadsheets, copy or cut and paste data and print results.