About Us:
CodeForce 360 is a trusted global IT talent partner helping Fortune 500 companies, system integrators, and enterprise organizations build high-performing technology teams. With over 16 years of industry expertise, we combine speed, precision, and market intelligence to deliver exceptional talent across today's most in-demand technologies.
About the Job- We are looking for an experienced Registered Nurse to join one of our enterprise client engagements. The ideal candidate should have strong expertise in RN license, NCQA, Medicare along with experience working in fast-paced enterprise environments.
Job Responsibilities:
- Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
- 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
- Performs other duties as assigned.
- Complies with all policies and standards.
Must have Skills:
- Requires a degree from an Accredited School of Nursing or Master’s degree in Behavioral Health or Social Work and 2 – 4 years of related experience.
- Knowledge of NCQA, Medicare and Medicaid regulations preferred.
- Knowledge of utilization management processes preferred.
License/Certification:
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
- LCSW- License Clinical Social Worker required or
- LMHC-Licensed Mental Health Counselor required or
- LPC-Licensed Professional Counselor required or
- Licensed Marital and Family Therapist (LMFT) required or
- Licensed Psychologist required
Required
RN license required
How To Apply
Job ID: JPC - 240841
Contact:
Name: Rohith Boorugula
Email:
Phone:
CodeForce 360 proudly provides equal employment opportunities to all employees and applicants and prohibits discrimination and harassment of any kind without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by applicable federal, state, or local laws.
