Clinical - Appeals Nurse

Position Summary:

Review and process Iowa Medicaid Member Appeals

Volume of appeals continues to increase and is at an all-time putting team at risk for liquidated damages if cases are not 100% resolved in 30 days.

Background & Context:

The Organization's appeals team is experiencing a surge in volume, requiring efficient case handling to avoid compliance penalties.

Key Responsibilities:

* Member appeal requests are received and assigned by the team lead, the appeals nurse is responsible for working the appeal start to finish

* Outreach attempts are made to member/provider

* A clinical review is completed and case sent to specialty review/MD

* Appeals nurse will write determination letters and close the case

* 30 calendar days to complete standard cases and 3 business days to acknowledge receipt of the case

Qualification & Experience:

* Education/Certification Required: Associates

* Licensure Required: LPN Preferred: RN

* Years of experience required: at least 2 years nursing experience, UM experience helpful

* Additional qualities to look for: The ideal candidate will thrive in a fast paced environment with frequently changing workloads. This role requires strong prioritization, organization, and adaptability.

* Top 3 must-have hard skills stack-ranked by importance

1 Customer service

2 Time management

3 Computer skills/ability to learn new systems