Ref No.: 16-00216
Location: Pittsburgh, Pennsylvania
Start Date: 01/22/2016
Aequor Healthcare Services is in need of a RN for a Case Management Position in the Pittsburgh Area. The contract position is for 13 weeks starting a.s.a.p.

Job Description or Additional Skills: This position coordinates and completes all medically necessary provider appeals. The provider clinical review is for all levels of services and all lines of business.

Interpret Medical Director notes and summarize into correspondence for provider and/or facility. Manage escalated provider issues as required. Prepare comprehensive Independent Review Entity Packets, including clinical justification of the Medical Director's decision which includes all applicable points from the specific policy, Evidence of Coverage statement and/or documentation submitted to which the decision pertains. Respond to providers in writing with the results of appeal review in accordance with Complaints and Grievances Department standards and all applicable regulatory requirements. Outreach to providers as appropriate to communicate decision.
Review and approve Administrative appeals, including retro authorizations and requests that meet medical criteria. (i.e. private duty nursing, DME, behavioral health, experimental and investigational, potential benefit exceptions, cases requiring prior authorization, etc. ) Review and investigate appeals from providers where decisions by the health plan Special Investigation Unit audit process have impacted reimbursement. Determine uphold or overturn of decision.

Review first and second level appeals for medical necessity, completes a comprehensive medical necessity packet summarizing clinical facts for the Medical Director review. Coordinates timely case review by a Health Plan Medical Director.

Review, investigate and complete appeals related to medical necessity, appropriate level of service and benefit coverage for all lines of business in required timeframes.

Track and trend appeals related to medical necessity, coding issues and other administrative reasons.

Work closely with Special Investigations Unit (SIU), Network Development, Claims, Community Care Behavioral Health, Provider Services, Member Services, Medical Management, Benefit Configuration, Compliance, Enrollment, Pharmacy Services, Reimbursement and Coding departments to ensure review processes are understood and meet Health Plan strategy for appropriateness of provider reimbursement as well as quality of care and services.

Dates: 1/4/2016 - 4/4/2016

Shift Days: Monday, Tuesday, Wednesday, Thursday, Friday
Shift Start/End Times: 08:00 AM - 04:30 PM

Please call Gina at 814-935-7084 to discuss the opportunities! Alternatively you can email your resume to me at

This is a great opportunity and this position will be filled quickly, please respond asap!

Perm, Travel, Contract and Per Diem shifts also Available Nationwide.

"We like referrals and will pay you for them too

Excellent Compensation package!
Weekly pay with direct deposit!
Tax Advantage program.
Completion Bonuses
401K Medical Dental and Vision
Travel Reimbursement

About Aequor Healthcare Services:
Aequor Healthcare Services is one of the premier staffing solutions firms in the nation. Since 1989 we have paved a way for Technical, Allied and Nursing Professionals to grow and have been able to offer some of the best positions and benefit packages in the industry. We are committed to personnel service above and beyond, for our clients and professionals alike. We currently have thousands of open positions Nationwide. If we don't have the location or setting in our current database that fits your needs. Aequor is committed to finding your specific interest and will direct market you to our healthcare client partners to find the opening that is right for you. That's just one way we are here to give you the personal attention you deserve!