Appeals & Grievance RN Lead

Wollborg Michelson Personnel Service Inc; Oakland (CA); On-site; USD 120,000 - 160,000; Full time

Job summary

Wollborg Michelson Recruiting in Oakland, CA seeks an RN Lead for Medicare Appeals and Grievances. The role reports to the Appeals and Grievances Manager and leads first-level appeal reviews for medical necessity, coding accuracy, policy compliance, and contract requirements.

Responsibilities include overseeing daily team activities, conducting training, and presenting cases to the Medical Director, while ensuring compliance with state and federal regulations and professional licensure standards.

Qualifications

• RN license in good standing.
• Knowledge of Nurse Practice Act and regulatory implications.

Responsibilities

• Review cases for medical necessity, coding accuracy, and policy compliance.
• Prepare and present appeal and grievance cases to Medical Director.
• Communicate determinations to providers and members.
• Manage daily team activities and quality reviews.
• Lead training, supervise staff, and drive process improvements.
• Stay current with applicable regulations and licensure requirements.
• Act as SME for quality-of-care concerns and clinical judgments.

Skills

Verbal communication

Attention to detail

Problem solving

Clinical judgment

Team leadership

Priority management

Process improvement

Education

Associate degree in nursing

Bachelor's degree preferred

Job description

Job Summary

Medicare Appeals and Grievances RN Lead Job Summary Reports to the Appeals and Grievances Manager and leads first-level appeal reviews for Medicare members. Reviews cases for medical necessity, coding accuracy, policy compliance, and contractual requirements using applicable coverage guidelines and nationally recognized clinical criteria.

Responsibilities

• Perform retrospective utilization reviews and first-level determination approvals using evidence-based guidelines, policies, and nationally recognized clinical criteria across applicable lines of business.
• Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
• Prepare and present appeal and grievance cases to the Medical Director for oversight and medical necessity determinations.
• Communicate determinations to providers and members in compliance with state, federal, and accreditation requirements.
• Manage daily team activities, inventory, spot audits, and monthly internal quality reviews.
• Motivate team members, facilitate clinical rounds, and conduct training as needed.
• Maintain current knowledge of applicable regulations, statutes, policies, certifications, and licensure requirements.
• Serve as a subject matter expert in identifying quality-of-care concerns and assessing services using clinical judgment.
• Manage documentation, compliance, training, inventory, and process improvement initiatives.
• Represent the team at cross-functional meetings and serve as a point of contact for escalations.

Requirements

• Associate degree in nursing required; bachelor s degree preferred.
• Active registered nurse license in good standing.
• Eight to ten years of nursing experience required.
• Leadership experience preferred.
• Knowledge of the Nurse Practice Act and the legal implications of nursing practice.

Skills

• Strong verbal communication skills.
• Excellent attention to detail.
• Effective problem-solving and critical-thinking skills.
• Ability to apply clinical judgment in complex appeal and grievance reviews.
• Ability to lead teams, manage priorities, and support process improvement.

Summary Qualification

• Registered nurse with extensive experience in medical necessity review, appeals, grievances, and utilization management.
• Strong knowledge of clinical guidelines, coding requirements, benefits, and regulatory compliance.
• Demonstrated ability to lead teams, manage inventory, conduct audits, and oversee quality initiatives.
• Experienced in communicating clinical determinations to providers, members, and medical directors.

Equal Opportunity Statement

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.