Clinical Grievance & Appeals Nurse Specialist

Wollborg Michelson Recruiting; Phoenix (AZ); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Equal Opportunity Employer

E-Verify participation

Job summary

Wollborg Michelson Recruiting is seeking a Grievance and Appeals Clinical and Administrative Specialist in Phoenix, AZ. You will investigate member and provider issues, coordinate timely resolutions, and ensure CMS-compliant responses within required timelines.

Candidates should have at least five years in CMS-related member services, prior authorizations, appeals and grievances, or claims. Active LPN/RN license and healthcare knowledge are required to interpret medical documents and billing

Qualifications

• CMS member services, prior authorizations, appeals and grievances, or claims experience required.
• Associate degree or nursing diploma required.
• Active LPN or RN license required.
• Knowledge of CMS manuals and billing/claims processes.
• Strong communication and analytical skills.

Responsibilities

• Investigate grievances and appeals and coordinate timely resolutions.
• Review information from members and providers to make determinations.
• Ensure responses comply with CMS requirements and timelines.
• Support CMS audits and related activities.

Skills

Grievance investigation

Appeals process

CMS regulatory compliance

Medical records interpretation

Billing & claims adjudication

Medical terminology & coding

Documentation review

Customer service

Critical thinking

MS Office

Education

Associate degree or nursing diploma

Tools

Microsoft Office

Job description

Wollborg Michelson Recruiting is seeking a Grievance and Appeals Clinical and Administrative Specialist in Phoenix, AZ. You will investigate member and provider issues, coordinate timely resolutions, and ensure CMS-compliant responses within required timelines.

Candidates should have at least five years in CMS-related member services, prior authorizations, appeals and grievances, or claims. Active LPN/RN license and healthcare knowledge are required to interpret medical documents and billing