About Workwarp
Workwarp is a dynamic and innovative healthcare organization dedicated to delivering exceptional quality care to a diverse population. We are committed to fostering a supportive and collaborative work environment where talented healthcare professionals can thrive and make a meaningful difference in the lives of our members. We are currently seeking a highly skilled and motivated Senior Clinical Appeals Registered Nurse to join our expanding Clinical Appeals team. This is a remote position based in New York, New York, offering a unique opportunity to shape patient care and ensure regulatory compliance within a leading healthcare system.
The Opportunity: Senior Clinical Appeals Registered Nurse
As a Senior Clinical Appeals Registered Nurse, you will play a pivotal role in our Clinical Appeals department, which is responsible for managing grievances, appeals, and external reviews for our key health plan product lines: Managed Long Term Care (MLTC), Medicare Advantage (MA), and Select Health. This is a challenging and rewarding position that offers a high degree of autonomy, professional growth, and the chance to directly impact patient outcomes and organizational compliance. You will be a key advocate for our members, ensuring their rights are upheld and that they receive appropriate and timely care.
Key Responsibilities:
- Regulatory Expertise: Maintain a comprehensive understanding of federal and state regulations pertaining to grievances and appeals, including those related to Medicare managed care, Medicaid, and managed long-term care. Proactively monitor changes in legislation and guidelines and translate them into practical application.
- Complex Case Management: Independently investigate, analyze, and resolve a wide range of complex grievances and appeals, with a strong emphasis on medical necessity, quality of care, and patient safety. This includes conducting thorough reviews of medical records, gathering relevant information from various stakeholders, and applying clinical judgment to reach fair and equitable resolutions.
- Timely and Accurate Resolution: Ensure all grievances and appeals are processed within mandated timeframes, meticulously documented, and fully compliant with all applicable regulatory standards. Proactively manage case timelines and escalate issues as necessary to ensure timely resolution.
- Service Coordination & Advocacy: Review and coordinate patient services in accordance with plan benefits and medical criteria. Prepare comprehensive documentation for physician review and manage prior authorization requests with a focus on patient needs and outcomes. Advocate for patients to ensure they receive the appropriate level of care and support.
- External Review Coordination: Manage the coordination of external case reviews with entities such as New York State (Fair Hearings) and CMS, ensuring full compliance with regulatory requirements and providing expert clinical support.
- Cross-Functional Collaboration: Collaborate effectively with diverse departments, including Claims, Medical Management, Legal, and Pharmacy, to facilitate seamless grievance and appeal resolutions. Consult with Medical Directors and other clinical experts as needed to ensure sound clinical decision-making.
- Process Improvement & Innovation: Actively contribute to the development and refinement of policies, procedures, and workflows to enhance department efficiency, improve customer service, and optimize the grievance and appeals process. Identify opportunities for process improvement and implement innovative solutions.
- Data Analysis & Reporting: Accurately enter data and assist in the compilation of reports on grievance and appeals processes, providing valuable insights to management and supporting data-driven decision-making.
- Member Communication & Education: Communicate effectively with members, families, and providers regarding the status of grievances and appeals, providing clear and concise information in a compassionate and professional manner.
- Quality Assurance & Compliance: Participate in quality assurance activities and contribute to the development and maintenance of compliance protocols to ensure adherence to regulatory requirements and organizational standards.
Qualifications:
- Licenses & Certifications: Current and unrestricted registration to practice as a Registered Nurse in the State of New York is mandatory.
- Education: Bachelor's degree in Nursing required. A Master's degree in Nursing is highly preferred.
- Experience: Minimum of three (3) years of progressive professional experience in healthcare, with at least two (2) years specifically dedicated to grievance and appeals or related areas such as medical or utilization management.
- Technical Proficiency: Proficient in Microsoft Office Suite (Word, Excel, PowerPoint) and demonstrated ability to navigate and utilize electronic health record systems.
- Skills & Abilities: Exceptional analytical, problem-solving, and critical thinking skills. Excellent written and verbal communication skills, with the ability to effectively communicate with diverse audiences. Proven ability to manage multiple cases simultaneously in a fast-paced environment. Strong attention to detail and commitment to accuracy. Ability to work independently and as part of a team.
Compensation & Benefits:
- Competitive Salary: We offer a competitive salary commensurate with experience and qualifications.
- Remote Work Environment: Enjoy the flexibility of a fully remote work environment, with a requirement for occasional in-office meetings (approximately one day per month).
- Comprehensive Benefits Package: We provide a comprehensive benefits package including medical, dental, and vision insurance, paid time off, and retirement savings plan.
- Professional Development: Opportunities for professional development and continuing education to support your career growth.
To Apply:
If you are a dedicated and experienced Registered Nurse seeking a challenging and rewarding career opportunity in a supportive and collaborative environment, we encourage you to apply! Click the link below to submit your application.
Apply Now
For more exciting career opportunities at Workwarp, please visit our careers page.
We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.