**Roles and Responsibilities:** + Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal + Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards + Communicates with members, providers, facilities, and other departments regarding appeals requests + Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards + Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices + Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically Medicare and medical necessity review. + Uses sound judgment, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards + Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals. + Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation. + Prepare case recommendations for medical review as necessary. **Requirements:** + 2 - 4 years of experience in processing appeals or utilization management + RN - Registered Nurse – State required Licensure and/or Compact State Licensure + Knowledge of utilization management processes + Knowledge of NCQA, Medicare and Medicaid regulations + Good communication (Demonstrate strong reading comprehension and writing skills) + Able to work independently, strong analytic skills Required shift timings: US daytime