Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond.  As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community.  Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day.  Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
 

Position Summary
 

The Utilization Appeals Review Nurse will be responsible for clinical review of member and provider appeals and/or claims disputes. Collaborating with our team of Medical Directors and internal stakeholders, you will use your clinical expertise to apply Martin’s Point medical policies, CMS and TRICARE regulations to deliver accurate, timely, and compliant appeal or claims disputes decisions.

Job Description

PRIMARY DUTIES AND RESPONSIBILITIES

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization. 

• Responsible for the review and resolution of clinical appeals and disputes
• Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues.
• Ensures care delivery aligns with specific line-of-business benefits while maintaining full compliance with contractual and regulatory standards, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. 
• Stays current with industry regulations and accreditation standards to ensure continuous operational compliance
• Consistently delivers high-quality outcomes that meet or exceed established departmental benchmarks and performance standards. Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings.
• Independently coordinates the clinical resolution with internal/external clinician support as required.
• This position will be accountable for appeals, claims disputes, and QOC review
• This is a full-time remote position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time).
• Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
• Assumes extra duties as assigned based on business needs.
• Weekend and holiday on-call coverage may be required.

POSITION QUALIFICATIONS

Education

• Associate Degree in Nursing (ADN)
• Bachelor’s degree in nursing preferred

Licensure/certification

• Active, unrestricted Compact Registered Nurse (RN) license.

Experience

• 3+ years of RN clinical experience, preferably in a hospital setting, along with experience in utilization management in a health plan UM department and in managing appeals or disputes
• Coding/CPC preferred

Knowledge

• Thorough understanding of CMS Medicare Advantage regulations (Parts C & D) and NCQA guidelines
• Thorough knowledge of MCG, Interqual of other clinical guidelines
• HIPAA & privacy requirements
• Concurrent, prior authorization and appeals review
• Critical thinking and case analysis
• Clinical writing and summarization
• Electronic UM systems
• Tricare regulation experience preferred
• MCQA standards experience preferred
• Claims disputes review experience preferred

Skills

• Ability to extract relevant clinical facts from progress notes, labs, imaging, and treatment plans.
• Correct use of MCG, and Martiin’s Point medical policies to determine medical necessity.
• Ability to identify inconsistencies, missing information, or red flags in documentation
• Understanding appeal levels, timeframes, coverage rules, and documentation requirements.
• Ability to produce rationales that meet CMS, TRICARE, and NCQA standards
• Ability to write clear, defensible rationales that explain the clinical and regulatory basis for the determination.
• Ability to write concise, objective, and compliant appeal rationales

Abilities

• Ability to analyze data metrics, outcomes, and trends.
• Ability to prioritize time and tasks efficiently and effectively.
• Ability to manage multiple demands.
• Ability to function independently.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org