Care Coordinator - Clinical Appeals RN

Location: Telecommuter; hiring is limited to specified U.S. states, including Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, and Wisconsin. Standard schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time.

Salary: $80,200–$125,600 national range; $84,200–$143,100 national plus range for higher-cost labor markets, including Western Washington and Alaska.

Company

hirify.global is a healthcare organization focused on improving customer outcomes and making healthcare work better.

What you will do

• Perform inpatient, concurrent, retrospective, benefit advisory, prior authorization, out-of-network, and treatment-setting reviews.
• Assess medical necessity and appropriateness using clinical criteria, medical policies, member benefits, eligibility, and provider contracts.
• Consult Medical Directors when requests do not meet applicable criteria or policies.
• Document clinical information and utilization management determinations accurately and on time.
• Identify opportunities for case management, member engagement, and disease management programs.
• Collaborate with Customer Service, Claims Operations, Sales and Marketing, Health Care Services, and other departments on consistent clinical processes.

Requirements

• Bachelor’s degree or four years of work experience.
• Current state licensure as a registered nurse.
• At least three years of clinical experience.
• Experience in utilization management.
• Experience working in the health plan industry.
• Ability to work the stated Pacific Time schedule and comply with accreditation, regulatory, quality, and timeliness requirements.

Culture & Benefits

• Medical, vision, and dental coverage with low employee premiums.
• Life and disability insurance, a 401(k) employer match, and a pension plan vested after three years.
• Paid time off, wellness and mental well-being resources, and counseling services.
• Tuition assistance for undergraduate and graduate education.
• Employee recognition programs and opportunities for ongoing learning and career development.