RN PROVIDER APPEALS COORDINATOR - MEDICAL APPEALS - 40 HOURS WEEKLY - DAY SHIFT
Full Time Benefit Eligible
Schedule: Monday through Friday, 8:00AM to 4:30PM. This position is primarily remote with the possibility of in person meetings and trainings periodically at our Troy headquarters.
GENERAL SUMMARY:
Unit Description:
Health Alliance Plan (HAP) is looking to grow our Medical Appeals Team with an experienced Registered Nurse! We are a team of Registered Nurses (3 and counting) and Utilization Review Coordinators (4) that review appeals for medical necessity using established medical criteria, readmission appeals, administrative appeals for provider and member appeals in partnership with our Medical Directors. If you have experience with prior authorizations, are known for your attention to detail, and are considering a nursing career away from bedside care, we want to meet you!
- Responsible for investigating Provider Appeal requests and Code Review inquiries for all Utilization Management divisions, including delegated entities.
- Summarize outcome of investigation for decision by Medical.
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and duties. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described above.
EDUCATION/EXPERIENCE REQUIRED:
- Nursing Diploma or equivalent.
- Bachelor's Degree in Health Care or related field preferred.
- Minimum of two (2) years of experience in clinical management of patients in an inpatient or ambulatory setting, or at least three (3) years of experience in Utilization Management or Case Management.
- Demonstrated knowledge of the InterQual or Milliman Care Guidelines criteria preferred.
- Knowledge of Medicare, Medicaid and NCQA guidelines and use of CMS website for research preferred.
- Knowledge of use of Microsoft Office Suite. Knowledge of ICD-10 and CPT coding, medical necessity criteria and medical terminology.
- Must work effectively with persons of varying position levels and diverse interests to reach consensus on resolution of problems.
- Excellent written and verbal communication skills.
- Must be able to interact professionally with physicians, members, and other internal and external customers.
- Ability to prioritize and coordinate workflow.
- Ability to manage multiple tasks simultaneously.
- Ability to work independently with limited supervision.
- Must have excellent organizational skills.
- Must have excellent interpersonal and telephone skills.
- Ability to make decisions and initiate appropriate actions based on analysis of data.
- Ability to participate in problem identification and resolution with team members.
- Knowledge of inpatient and outpatient procedures and practices.
- Knowledge of NCQA, CMS, DOL, ERISA and other regulatory body rule preferred.
- Computer skills including Windows and Microsoft Word. Excel and Access preferred.
CERTIFICATIONS/LICENSURES REQUIRED:
- Registered Nurse (RN) with current Michigan licensure.
Additional Information
- Organization: HAP (Health Alliance Plan)
- Department: Medical Appeals
- Henry Ford Health Location: HAP (Health Alliance Plan)
- Shift: Day Job
- Union Code: Not Applicable
Henry Ford Health System
Jul 10, 2025