Appeals & Grievance Nurse Analyst

Jobtailor; Deutschland; Remote; EUR 52.000 - 78.000; Vollzeit

Zusammenfassung

Jobtailor is seeking an experienced Registered Nurse to review and process member and provider appeals, ensuring timely resolution in line with CMS, Medicare, and TennCare guidelines.

You will evaluate cases, gather medical records, and prepare files for Medical Director review, maintaining strong communication with clinical and non-clinical staff. A Tennessee RN license is required; sponsorship is not available.

Qualifikationen

• Active RN license in Tennessee.
• 3 years of clinical nursing experience.
• Knowledge of Medicare, CMS, and TennCare regulations.
• Experience in appeals and grievance processes.
• Clinical knowledge with strong analytical skills.
• Accurate data entry and attention to detail.

Aufgaben

• Review and process member and provider appeals.
• Ensure timely resolution in compliance with CMS, Medicare, and TennCare guidelines.
• Evaluate cases and manage multiple priorities within tight turnaround times.
• Review clinical records and summarize findings for Medical Director review.
• Prepare case files for Medical Director review.
• Collaborate with clinical and non-clinical staff to resolve appeals and grievances.

Kenntnisse

Analytical skills

Attention to detail

Customer-focused

Oral and written communication

Interpersonal skills

Organizational skills

Ausbildung

Active RN License in Tennessee

Tools

Microsoft Office Suite (Outlook, Word, Excel, PowerPoint)

Jobbeschreibung

• Review and process member and provider appeals
• Ensure timely and accurate resolution in compliance with CMS, Medicare, and TennCare guidelines
• Evaluate cases, determine next steps, and manage multiple priorities within strict turnaround times
• Review clinical and medical records and summarize findings for Medical Director review
• Research and document the substance and validity of appeals or quality‑of‑care grievances using multiple systems
• Evaluate medical necessity documentation, including complex situations
• Conduct outreach for clinical information as applicable
• Prepare case files for Medical Director review
• Create individualized member‑and provider‑specific appeal and quality‑of‑care grievance response letters
• Assess response letters for accuracy and compliance and recommend improvements
• Collaborate with clinical and non‑clinical staff to resolve appeals and quality‑of‑care cases
• Meet turnaround times as short as 24–72 hours

Requirements

• 3 years of clinical nursing experience required
• Registered Nurse (RN) with active license in Tennessee, or an active license in the state of residence if participating in the Nurse Licensure Compact Law
• Knowledge of Medicare, CMS, and TennCare regulations
• Experience in appeals and grievance processes
• Clinical knowledge
• Strong analytical skills and attention to detail
• Customer-focused approach
• Case management skills
• Accurate data entry
• Proficiency in Microsoft Office (Outlook, Word, Excel, and PowerPoint)
• Ability to work independently with minimal supervision or in a team environment
• Ability to handle multiple projects
• Excellent oral and written communication skills
• Strong interpersonal and organizational skills
• Ability to work a 40-hour week with flexibility for potential weekend coverage
• Sponsorship is not available for this role

Core Competencies

Demonstrates expertise in clinical nursing with a focus on appeals and grievance processes, ensuring compliance with Medicare, CMS, and TennCare regulations. Proficient in case management and effective communication, with strong analytical skills to evaluate medical necessity documentation.

Highest-signal resume keywords

• Registered Nurse (RN) License
• Clinical Nursing Experience
• Knowledge of Medicare and CMS Regulations
• Experience in Appeals and Grievance Processes
• Strong Analytical Skills

ATS Optimization Keywords

Hard Skills

• Clinical Knowledge
• Case Management Skills
• Accurate Data Entry
• Medical Necessity Evaluation
• Appeal Documentation
• Response Letter Creation
• Compliance Assessment

Soft Skills

• Attention to Detail
• Customer-Focused Approach
• Excellent Oral and Written Communication Skills
• Strong Interpersonal Skills
• Organizational Skills

Certifications & Qualifications

• Active RN License in Tennessee

Industry Keywords

• CMS Guidelines
• Medicare Regulations
• TennCare Guidelines
• Quality-of-Care Grievances
• Member Appeals

Tools & Technologies

• Microsoft Office (Outlook, Word, Excel, PowerPoint)