Appeals & Grievances RN
Appeals & Grievances Nurse Job Summary:
- Supports the organization by working to resolve provider payment disputes through advanced and complicated case review of the appropriateness of medical care requiring considerable clinical judgment, independent analysis, and detailed knowledge of managed care and organizational guidelines.
- Manages the consolidation of the complaints and grievance activities on a quarterly basis, and prepares monthly, quarterly and annual reports on assigned quality improvement activities.
- Maintains strict compliance with federal, state and NCQA requirements and guidelines
Appeals & Grievances Nurse Background:
Appeals & Grievances Nurse Benefits:
- Current, valid, and unrestricted state Registered Nurse (R.N.) license.
- Minimum of 2 years acute care clinical nursing experience
- Minimum of 1 year previous experience in Denials & Grievances & Appeals and/or Utilization Review in a Managed Care Organization.
- Minimum of 2 years of recent experience at a health plan or other Managed Care Organization (HMO/TPA/IPA/etc).
- Requires at least 1year of customer service experience communicating directly with members to identify their true complaint and obtain any additional information to resolve their case.
- Experience using standardized clinical guidelines (preferably InterQual) is required.
- Must be able to differentiate between PCP rendered care and specialty care; and be able to identify clinical quality of care issues.
- Understand Utilization Review guidelines, Medicare and Medicaid regulations, and appropriate state plan requirements.
- ZERO cost health insurance plan, dental and vision
- Matching 401(k) with instant vesting
- Company-wide annual bonus (10%-13% of salary), & generous PTO (plus paid holidays!)
- Wellness programs & on site gym and cafeteria
- Tuition assistance