Appeals & Grievances Nurse (RN or LVN) – Managed Care
*** This is a Full Time, Benefits Available, CONTRACT opportunity, expected to last 5-6 months or longer! ***
Appeals & Grievances Nurse Job Summary:
Appeals & Grievances Nurse Background:
- 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
- Requires a valid, unrestricted state license as a Registered Nurse (R.N.) or Licensed Vocational Nurse (L.V.N.).
- Prefer candidates with a Bachelors of Science in Nursing (BSN) or related healthcare field.
- Around 3-5 years of acute care clinical nursing experience.
- Requires 1-2 years previous experience in Denials, Appeals, Grievances, Complaints at a managed care organization.
- Prefer around 2-3 years recent experience working for a managed care organization (Health Plan, MSO/TPA, HMO, IPA, etc).
- Understand Utilization Review guidelines, Medicare and Medicaid regulations, and appropriate state plan requirements.
- Experience using standardized clinical guidelines, such as InterQual or Milliman/MCG, is required.
- Possess excellent communication and interpersonal skills; in person, over the phone, and in writing.
- Able to work independently and multitask, handling multiple projects and prioritizing workflows.