Appeals & Grievances RN (PA or NJ Licensed)

Clearlink Partners; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Clearlink Partners is seeking an experienced Registered Nurse to support case reviews and denial processes within managed care settings. You will review clinical information, prepare case summaries for medical director review, and ensure compliance with state and federal turnaround times.

The role emphasizes utilization management, patient education, and advocacy for cost-effective, quality care across Medicare/Medicaid programs.

Qualifications

• Minimum 5+ years of acute clinical experience.
• Minimum 2 years in a managed care environment across lines of business.
• 2+ years of appeals and grievances in managed care.

Responsibilities

• Review cases per state and federal guidelines within turnaround times.
• Ensure all clinical information is available for full review.
• Prepare claims and case summaries for MD review.
• Assist with denial overturns and utilization management.
• Provide outstanding customer service to internal and external stakeholders.
• Work across the health care spectrum to improve quality and access.

Skills

Clinical reasoning

Communication skills

Documentation & recordkeeping

Teamwork

Problem solving

Education

Registered Nurse license (PA or NJ)

Tools

Microsoft Office

Job description

Company Description

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.

Company Description

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.

We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Position Responsibilities

Specific

• Consider, review and evaluate cases in compliance with state and federally mandated turn-around-times and process requirements
• Ensure that all necessary clinical information is available to allow for a full and fair review
• Outreach as necessary to provider/provider staff for clarification or additional information needed
• Prepare claims and case summary for MD review and appropriate decision
• Ensure rationales are appropriate and supported by guidelines in accordance with regulatory requirements
• Access and review various resources to support denial or overturn denial

General

• Perform daily work with a focus on the core principles of managed care: Patient Education, Wellness and Prevention Programs, Early Screening and Intervention & Continuity of Care
• Work proactively to expedite the care process
• Identify priorities and necessary processes to triage and deliver work
• Empower members to manage and improve their health, wellness, safety, adaptation, and self-care
• Assess and interpret member needs and identify appropriate, cost-effective solutions
• Identify and remediate gaps or delays in care/ services
• Advocate for treatment plans that are appropriate and cost-effective
• Work with low-income/ vulnerable populations to ensure access to care and address unmet needs
• Gather and evaluate clinical information to assess and expedite referrals within the healthcare system including consideration of alternate levels of care and services
• Facilitate timely and appropriate care and effective discharge planning
• Work collaboratively across the health care spectrum to improve quality of care
• Leverage experience/ expertise to observe performance and suggest improvement initiatives
• Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes
• Ensure individual and team performance meets or exceeds the performance competencies and metrics
• Contribute actively and effectively to team discussions
• Share knowledge and expertise, willingly and collaboratively
• Provide outstanding customer service, internally and externally
• Follow and maintain compliance with regulatory agency requirements

Position Qualifications

Competencies

• Ability to translate member needs and care gaps into a comprehensive member centered plan of care
• Ability to collaborate with others, exercising sensitivity and discretion as needed
• Strong understanding of managed care environment with population management as a key strategy
• Strong understanding of the community resource network for supporting at risk member needs
• Ability to collect, stage and analyze data to identify gaps and prioritize interventions
• Ability to work under pressure while managing competing demands and deadlines
• Well organized with meticulous attention to detail
• Strong sense of ownership, urgency, and drive

Experience

• Registered Nurse with current unencumbered Pennsylvania or New Jersey license.
• Minimum of 5+ years of acute clinical experience
• Minimum 2 years experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.)
• 2+ years of appeals and grievance experience in managed care environment
• Strong knowledge of utilization management processes and industry best practice
• Indepth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual, etc.)
• Detailed knowledge and demonstrated competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care.
• HMO and risk contracting experience preferred
• In-depth knowledge of current standard of medical practices and insurance benefit structures
• Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills
• Proficiency in Microsoft Office
• The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families
• Excellent analytical-thinking/problem-solving skills
• The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads
• The ability to offer positive customer service to every internal and external customer

Physical Requirements

• Must be able to sit in a chair for extended periods of time
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
• Must be able to fluently communicate both verbally and in writing using the English language

Other Information

• Expected Hours of Work: Friday 8am – 5 pm EST; with ability to adjust to Client schedules as needed
• Travel: May be required, as needed by Client
• Direct Reports: None
• Time Zone: Eastern or Central
• Salary Range: $70,000 - $100,000

EEO Statement

It is Clearlink Partners policy to provide equal employment opportunity to all employees and applicants for employment without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit based factor in accordance with all applicable laws, directives and regulations of federal, state and city entities. Pay ranges discussed, stated, or detailed in relevance to this position are a minimum and maximum target wage for this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.