Nurse Supervisor Salary in Nashville, TN

Possess a thorough working knowledge of the revenue cycle management process. Responsible for the research and resolution of aging account receivables to that are either unpaid or incorrectly paid. Demonstrate the company's core values of respect, honesty, integrity, diversity, inclusion, and safety.At The Little Clinic, we are on a mission to simplify healthcare in America. We take pride in knowing we are helping individuals live healthier lives right in our communities. If you have a passion for helping others, we want to hear from you! Our clinics are staffed by board-certified nurse practitioners or physician assistants, licensed practical nurses, and patient care technicians who all work as a team to supply high-quality, affordable healthcare found in convenient retail settings. The primary focus of our healthcare team is to promote health and wellness through diagnosis and treatment of illnesses, preventative medicine, and individualized patient education. Here, people matter. That's why we strive to supply the ingredients you need to create your own recipe for success at work and in life. We help feed your future by supplying the value and care you need to grow. So, whether you're looking for balanced, competitive benefits and rewards or ongoing opportunities for growth and development- we have you covered. We are always looking for extraordinary talent to join our growing team!Minimum Position Qualifications: High school diploma 1+ year of insurance follow-up including working knowledge of the appeals resolution process Strong written, and oral communication skills Analytical and problem solving capabilities with close attention to detail. Excellent organizational and follow-up skills Thorough working knowledge of revenue cycle management including medical terminology,ICD-9, ICD-10, CPT-4 coding, Medicare reimbursement guidelines, billing and collection practices Ability to read and interpret EOB's Highly self-motivated, with ability to work independently and meet deadlines Ability to remain flexible during times of change and adjusts promptly and effectively Must be able to learn, understand, and apply new technologies Analyze, audit and resolve claims outstanding, denied, or incorrectly paid Review and respond to payer correspondence. Submit appeals as needed for denied claims. Contact insurance companies and navigate payer websites in order to secure and expedite insurance payments. Resolves patient billing inquiries. Document in detail all actions taken in accounts receivable system. Meet productivity expectations as outlined by supervisor. Recognize, document and notify Team Lead of trends resulting in nonpayment or incorrectly paid claims. Answer and resolve inbound calls from insurance carriers. Participate in process improvement initiatives as needed. Keep current with Medicare and other third party administrators regulations and procedures. Manage any special projects requested by supervisor or team lead. Must be able to perform the essential functions of this position with or without reasonable accommodation.

Nurse Practitioner (NP) performs various functions, such as diagnose, treat and manage certain diseases; perform physical exams and order tests; and write prescriptions. The NP can work without doctor supervision and can be a patient's primary care provider. This position will also practice primary care and family medicine in collaboration with a faculty physician.Daily Operations:• Performs preliminary assessment of patient through observation and interview, and physical assessment; appropriately diagnose and treat identified health problems within scope of practice; identifies patient's concerns.• Communicates procedures to patient to maximize emotional and physical comfort. Communicates procedures to patient to maximize emotional and physical comfort. Evaluates findings of examinations and procedures performed; documents in patient's record• Notifies physician when finds problems or abnormalities; performs physician examinations and procedures according to guidelines; documents inpatient chart. Identifies patient/family education needs regarding health status. Completes reports and submits to supervisor as requested. Maintains strict confidentiality in matters relating to patients and clinic personnel.• Utilized appropriate channels to communicate stressful situations and problems. Maintains flexibility in relation to patient assignment and work schedule.• Demonstrates accurate knowledge of legal implications and appropriate application of clinical and administrative policies and procedures.• Demonstrates accurate knowledge and appropriate application of clinical and administrative policies and procedures.• Practices current safety knowledge, infection control and sterilization policies, and procedures.• Actively participates in Quality Assessment programs• Responds appropriately in actual or simulated emergencies and demonstrates knowledge of fire, STAT and disaster procedures.• Provides proper cleaning and care for equipment and supplies and preventive maintenance for equipment• Performs other related duties as assigned by Executive Director, Medical Director or Supervisor.Required Skills: • Demonstrates a general understanding and knowledge of primary care, family medicine, and the Elam Mental Health Center Clinic office standards, procedures, medical terminology, and medical office practices.• Demonstrates a general understanding and knowledge of front/back office standards, procedures, medical terminology, and medical office practices.• Ability to handle multiple tasks, independently, under pressure.• Core Competencies; Patient Assessment, Clinical Procedure with Scope of Service• Knowledge of examination, diagnostic, and treatment room procedures.• Knowledge of medical equipment and instruments to administer patient care.• Knowledge of OSHA, Infection Control, and safety hazards and precautions to establish a safe working environment.• Knowledge of chart documentation requirements and recording test results.• Skill in establishing and maintaining effective working relationships with patients, medical staff, and the public.• Ability to maintain quality control standards.• Ability to interpret, adapt and apply guidelines and procedures.• Ability to operate computer and printer, general office equipment, and telephone equipmentRequired Education and Experience:The educational requirements for nurse practitioners vary by state but most require a Master's or Doctoral degree or post-Master's certificate. Preferred graduate of an approved adult or family nurse practitioner program. Must be a registered nurse in the State of Tennessee and be board certified/board eligible to practice as an adult or family nurse practitioner. Eligible for a certificate of fitness to prescribe medication in the State of Tennessee, if applicable.

The Mental Health Specialist will assist Program Manager in carrying out the clinical service plan for their assigned program. This will include providing and supervising individual therapy, group therapy, family therapy, and advocacy for assigned clients. The Mental Health Specialist will ensure that clinical services are provided according to program structure and schedule.Daily Operations• Provide clinical services (such as group therapy and individual counseling) utilizing best practices utilizing an ACT model for group and individual.• In collaboration with the Program Manager, provides behavioral and therapeutic structure.• Responsible for appropriately intervening and/or reporting program violations as they occur.• Collect and report statistical data to administration as required by funding and other agencies.• Provide psycho-educational groups and family counseling when appropriate.• Maintain a functional knowledge of best practices for service delivery that are trauma-informed, client-centered, and goal-oriented such as Motivational Interviewing.• Maintain, and practice skills regarding sensitivity to the cultural and socioeconomic backgrounds of clients and others contacted in carrying out job responsibilities.• Verify clients have received new client's orientation, insuring full understanding of program rules and procedures within twenty-four (24) hours of their arrival.• Utilizing appropriate forms hardcopy or electronic, document group and individual sessions with clients.• Maintain clinical records and required paperwork in compliance with agency standards.• Attend and participate in treatment team meetings in order to give and receive client condition reports.• Attend all appropriate client care conferences and staff meetings.• Participate in funding agency training activities as required.• Perform other departmental mission related duties as assigned by supervisor.• Be courteous, tactful, and discrete in relating to the public, other staff, and clients.• Adhere to the guidelines as stated in the Meharry Medical College Policy and Procedures Manual.• Provide other services that benefit the program and/or agency as assigned by the Program Manager or Clinical Director.Required Skills• A comprehensive knowledge of homeless services• Ability to interact effectively with staff, clients, agencies, etc.• Demonstrated effective clinical skills.Required Education and Experience• M.A. or M.S. in the Social Services Field with the ability to provide clinical services to mental health or substance abuse.

The Registered Nurse will work under the supervision of the Nurse Manager. The RN provides patient care in accordance with regulatory, licensing and accreditation standards. Assists in carrying out the medical components of the clinical service plan for the respective unit.Daily Operations Provide physical care for clients commensurate with RN training and under the supervision of Nurse Manager/Physician. (Details further explain in job description.) Assists the physician in assessments, physical examinations and treatments such as taking blood pressure, temperature, pulse and respiration when needed. Collecting specimens for laboratory exams as ordered and needed. Also gives injections or TB skin test as per physician orders. Maintain clinical records and required paperwork in compliance with agency standards. Observes, records and reports indicative signs and symptoms of clients physical and mental conditions. Prepare, administers, and records the administration of medication as required. Receives and gives report on clients at the beginning and end of each work shift.Adhere to procedures regarding medication management. Participated as team member in treatment planning for each individual patient. Provide education pertaining to health, hygiene, nutrition, and prenatal issues as needed.Responsible for counting, recording, and keeping all controlled medications properly secured. Give reports on clients at the beginning and end of each work shift. Carries out college's policy and procedures.Assist in developing nursing procedures as neededPerform other departmental duties as assigned by supervisor.Attend nursing monthly meeting, all necessary training assigned by Meharry Medical College, State of Tennessee and any other accrediting agency requirements assigned by the training coordinator.Performs other related duties as assigned.Required SkillsAbility to perform RN dutiesAbility to establish and maintain an effective working relationship with othersAbility to react calmly and effectively in life threatening situations to consumers and in other emergency situationsAbility to participate in the preparation of a variety of operational records and reportsAbility to express oneself, clearly, and concisely, both orally and in writingCertification in CPR, First Aid, the Heimlich maneuver, and competency in AED training and administrationRequired Education and Experience:RN training and TN licensure required.Minimum of six months to one year related experience.

Position SummaryThe Home Health Licensed Practical/Vocational Nurse is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Health Licensed Practical/Vocational Nurse administers skilled nursing care to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Home Health Registered Nurse Case Manager. S/he services are furnished in accordance with agency policies.Position Specific ResponsibilitiesImplements/follows the nursing care plan for each patient.Provides nursing services, treatments, and diagnostic and preventive procedures as assigned.Initiates preventive and rehabilitative nursing procedures as appropriate.Observes signs and symptoms and reports to the physician and Registered Nurse Case Manager (RNCM) reactions to treatments, including drugs and changes in the patient's physical or emotional condition.Teaches and counsels the patient and family/significant others regarding the nursing care needs and other related problems of the patient at home.Evaluates with the Home Health RNCM the effectiveness of the LP/VN's nursing service to the patient and family under the guidance of the RNCM.Maintains accurate and complete records of observation, treatments, and care of patients.Participates in medical record audits as assigned.Attends staff meetings, patient care conferences, and in-services as scheduled.Is responsible for submitting any changes in schedule to the Director of Clinical Services/Clinical Supervisor on a daily basis; participating in patient care conferences to discuss the need for involvement of other members of the health team, such as physical and speech therapists.Prepares clinical and progress notes and submits them within 24 hours of visit.Assists the physician and Home Health RNCM in performing specialized procedures.Prepares equipment and materials for treatments.Observes aseptic techniques as required.Assists in patient learning and appropriate self-care techniques.Ensures that all care is provided with respect for patient rights.Reports all grievances and complaints made by patients or families to the appropriate persons.Reports all allegations of patient abuse and/or misappropriation of patient's property as appropriate.Follows standard precautions and infection control procedures.Reports all accidents and incidents observed.Identifies and responds appropriately to emergency situations.Observes the safety needs of the patients.Provides documentation of patient's visit on the clinical record accurately, timely, and appropriately per agency policies.Develops treatment appropriate to patients' disease progression in conjunction with the Home Health RNCM.Addresses patients' care needs with families and significant others as appropriate.Maintains confidentiality of necessary information.Maintains proper documentation for billing per policy.Interfaces with patients, families, and staff to ensure customer satisfaction.Communicates effectively with patients, families, and other healthcare providers.Regular attendance is an essential function.Performs other duties as assigned.Education And/or ExperienceCertificate of an accredited program of Practical or Vocational Nursing as approved by the state required.Two (2) years of experience as an LPN in a clinical care setting preferred.Experience in skilled nursing, preferably in hospice, home health care, oncology or emergency care preferred.SkillsMathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications.Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy.Certifications, Licenses, and RegistrationsActive and unencumbered Licensed Practical Nurse or Licensed Vocational Nurse in the state(s) of employment required.Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization.At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Faith Technologies, a division of Faith Technologies Incorporated (FTI), is an energy expert and national leader in electrical planning, engineering, design and installation. As a comprehensive authority in the field of electrical and energy services, Faith leads industry change through a dedicated investment in technology, strategic project consulting and process engineering that drives productivity, value, and above all, safety. Through innovative practices, Faith drives trends in growth and development with continual investment in their merit-based employees' skill, leadership and career development.Specialty Systems Technicians are responsible for a wide range of systems installations, troubleshooting and maintenance through well-versed knowledge of applicable codes and standards. Our job site professionals thrive under self-directed management to complete projects on time and safely. All job site employees participate and drive safety initiatives such as tool-box talks and operational risk management meetings to proactively identify safe practices for our people. Our crews rely on teamwork to drive results through strategic use of partnerships and planning. We pride ourselves on a "Ground up Growth" mentality that puts you in the spotlight. Becoming a member of the Faith Technologies team means you've officially put yourself in the driver's seat of your career. Through our career development and continued education programs, you'll have options to position yourself for success. Faith is a "Merit to the Core" organization, and we pride ourselves on our ability to reward and recognize top performers. MINIMUM REQUIREMENTS Education: Completion of Electronic Systems Technician (EST) Apprenticeship Program (if applicable) Holds BICSI or NICET CertificationRequired: The ability to effectively communicate in the English language. This includes the ability to understand the spoken and written word as well as speak in English. Travel: 5-10%Work Schedule: This position works between the hours of 6 am to 6 pm, Monday through Friday. May vary based on customer demands and can include, but is not limited to: nights, weekends, and holidays. KEY RESPONSIBILITIES Provides installation and troubleshooting for a wide range of systems including voice and data, fiber optics, fire alarm, security, access control, closed circuit television, nurse call, etc. Analyzes blueprints effectively for job site knowledge. Evaluates upcoming tasks and anticipates equipment, procedures and training needs. Enforces a safe job site and maintain compliance with company safety, OSHA and customer-specific safety standards. Demonstrates excellent customer relations though utilization of effective problem-solving techniques. Provides direction, training, and mentorship to Helpers/Apprentices. The job description and responsibilities described are intended to provide guidelines for job expectations and the employee's ability to perform the position described. It is not intended as a comprehensive list of all functions, responsibilities, skills or abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. SURGE your career forward!Employees at FTI grow faster because they are a part of a nationally leading team of electrical planners, engineers, designers, electricians, and business professionals. Your Personal Growth : Build your career path by taking advantage of our industry leading training and leadership development programs. Leverage Technology : Our virtual design and build programs that offer the latest in robotic total stations, 3D scanning, virtual and augmented reality and drone surveillance and assessment. Uncompromised Safety : When we see others in our space averaging 2.7 safety rating and ours average .42, you know that we value you and your safety above all else.We offer competitive, merit-based wages; career path development and flexible and a robust benefits package that boasts everything from paid training, tuition reimbursement and a top-notch wellness program.We pride ourselves on a "Ground up Growth" mentality that puts you in the spotlight. Becoming a member of the FTI team means you've officially put yourself in the driver's seat of your career. Through our career development and continued education programs, you'll have options to position yourself for success.FTI is a "Merit to the Core" organization, and we pride ourselves on our ability to reward and recognize top performers.BENEFITS ARE THE GAME CHANGERFTI enriches the lives of its employees through industry-leading total rewards. Our compensation, benefits, time off, and wellness programs are designed to reward individual results that create team success, improve financial security for our employees and their families, and encourage healthy lifestyles. As an eligible employee*, your programs include:Medical, Dental, Vision, and Prescription Drug InsuranceCompany-Paid Life and Disability InsuranceFlexible Spending and Health Savings AccountsAward-Winning Wellness Program and Incentives401(k) Retirement & 401(a) Profit Sharing PlansPaid Time OffPerformance Incentives/BonusesTuition ReimbursementAnd so much more!*Regular/Full-Time Employees are eligible for FTI benefit programs.We stand strong in our values as we work to Create World-Class Opportunities to Succeed through:Uncompromised focus on keeping people SAFE.Building TRUST in everything we do.REDEFINING what's possible.Rewarding individual results that create TEAM SUCCESS.If you're ready to learn more about growing your career with us, apply today!Faith Technologies, Inc. (FTI) is an Affirmative Action Employer/Equal Opportunity Employer. FTI will not discriminate against applicants based on race, color, religion, national origin, sex (including pregnancy and gender identity), sexual orientation, genetic information, or because they are an individual with a disability or a person 40 years old or older. Faith Technologies, Inc. will take affirmative action to provide equal opportunity in apprenticeship and will operate the apprenticeship program as required under Title 29 of the Code of Federal Regulations, part 30.

Cigna Medicare Part C Appeals Reviewer: Appeals Processing AnalystWe will depend on you to communicate some of our most critical information to the correct individuals regarding Medicare appeals and related issues, implications and decisions.The Case Management Analyst reports to the Supervisor/Manager of Appeals and will coordinate and perform all appeal related duties in a Medicare Advantage Plan. These appeals will include requests for decisions regarding denials of medical services as well as Part B drugs. The Case Management Analyst will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.This position is full-time (40 hours/week) with the scheduled core business hours generally 7:00 am - 6:00 pm CST - Thursday through Sunday with occasional holiday coverage. The position requires 4 ten hour shifts per week. Job Requirements include, but not limited to: Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part CAbility to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was deniedIdentify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director. Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/responseComplete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc.Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendanceAdhere to department workflows, desktop procedures, and policies.Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.Read Medicare guidance documents report and summarize required changes to all levels department management and staff.Support the implementation of new process as needed.Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. .Understand and investigate billing issues, claims and other plan benefit information. .Assist with monitoring, inquiries, and audit activities as needed.Additional duties as assigned.QualificationsEducation: Licensed Practical Nurse (LPN) or Registered Nurse (RN)3-5 years' experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for serviceWorking knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.Must have the ability to work objectively and provide fact based answers with clear and concise documentation.Proficient in Microsoft Office products (Access, Excel, Power Point, Word).Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.Ability to multi-task and meet multiple competing deadlines.Ability to work independently and under pressure.Attention to detail and critical thinking skills..Learning and Applying QuicklyA relentless and versatile learnerOpen to changeAnalyzes both successes and failures for clues to improvementExperiments and will try anything to find solutionsEnjoys the challenge of unfamiliar tasksQuickly grasps the essence and the underlying structure of anythingWritten CommunicationsIs able to write clearly and succinctly in a variety of communication settings and stylesCan get messages across that have the desired effectFunctional/Technical SkillsClinical and Non Clinical functional or technical proficiencyAppropriate judgment and decision making becauseKnowledge of applicable policy and business requirementsComputer skills and ability to work in various system applications.Detail oriented and Has the functional and technical knowledge and skills to do the job at a high level of accomplishmentTime ManagementSpends his/her time on what's importantQuickly zeros in on the critical few and puts the trivial many asideCan quickly sense what will help or hinder accomplishing a goalEliminates roadblocksUses his/her time effectively and efficientlyConcentrates his/her efforts on the more important prioritiesGets more done in less time than othersCan attend to a broader range of activitiesProblem SolvingUses rigorous logic and methods to solve difficult problems with effective solutionsProbes all fruitful sources for answersCan see hidden problemsLooks beyond the obvious and doesn't stop at the first answersIs excellent at honest analysisIf you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Cigna Medicare Part C Appeals Reviewer: Appeals Processing AnalystWe will depend on you to communicate some of our most critical information to the correct individuals regarding Medicare appeals and related issues, implications and decisions.The Appeals Processing Analyst reports to the Supervisor/Manager of Appeals and will coordinate and perform all appeal related duties in a Medicare Advantage Plan. These appeals will include requests for decisions regarding denials of medical services as well as Part B drugs. The Case Management Analyst will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.This position is full-time (40 hours/week) with the scheduled core business hours generally 8:00 am - 5:00 pm CST - Monday through Friday with occasional weekend and holiday coverage. The position requires 5 eight hour shifts per week. Job Requirements include, but not limited to: Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part CAbility to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was deniedIdentify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director. Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/responseComplete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc.Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendanceAdhere to department workflows, desktop procedures, and policies.Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.Read Medicare guidance documents report and summarize required changes to all levels department management and staff.Support the implementation of new process as needed.Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. .Understand and investigate billing issues, claims and other plan benefit information. .Assist with monitoring, inquiries, and audit activities as needed.Additional duties as assigned.QualificationsEducation: Licensed Practical Nurse (LPN) or Registered Nurse (RN)3-5 years' experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for serviceWorking knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.Must have the ability to work objectively and provide fact based answers with clear and concise documentation.Proficient in Microsoft Office products (Access, Excel, Power Point, Word).Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.Ability to multi-task and meet multiple competing deadlines.Ability to work independently and under pressure.Attention to detail and critical thinking skills..Learning and Applying QuicklyA relentless and versatile learnerOpen to changeAnalyzes both successes and failures for clues to improvementExperiments and will try anything to find solutionsEnjoys the challenge of unfamiliar tasksQuickly grasps the essence and the underlying structure of anythingWritten CommunicationsIs able to write clearly and succinctly in a variety of communication settings and stylesCan get messages across that have the desired effectFunctional/Technical SkillsClinical and Non Clinical functional or technical proficiencyAppropriate judgment and decision making becauseKnowledge of applicable policy and business requirementsComputer skills and ability to work in various system applications.Detail oriented and Has the functional and technical knowledge and skills to do the job at a high level of accomplishmentTime ManagementSpends his/her time on what's importantQuickly zeros in on the critical few and puts the trivial many asideCan quickly sense what will help or hinder accomplishing a goalEliminates roadblocksUses his/her time effectively and efficientlyConcentrates his/her efforts on the more important prioritiesGets more done in less time than othersCan attend to a broader range of activitiesProblem SolvingUses rigorous logic and methods to solve difficult problems with effective solutionsProbes all fruitful sources for answersCan see hidden problemsLooks beyond the obvious and doesn't stop at the first answersIs excellent at honest analysisIf you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.