CMS Grievance & Appeals Nurse Specialist

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

Job summary

Wollborg Michelson Recruiting seeks a Grievance and Appeals Clinical and Administrative Specialist to serve as SME for Part C and Part D grievances and appeals, investigating member, provider, claim processing and customer service issues, coordinating timely resolutions in line with CMS requirements.

Answerable for CMS audits, regulatory compliance, and accurate benefit determinations, this role demands strong analytical skills and attention to detail to deliver quality service in a health plan

Qualifications

• At least five years of CMS member services, prior authorizations, appeals and grievances, or claims functions.
• Current, active, unrestricted LPN or RN license.
• Knowledge of CMS manuals and healthcare billing and claims adjudication processes.

Responsibilities

• Maintain knowledge of health plan operations, workflows, system requirements, plan benefits, authorizations, referrals, provider networks, claims, and regulatory compliance.
• Maintain current knowledge of CMS rules governing grievance and appeal processes and participate in CMS audits.
• Coordinate the investigation and resolution of complex grievances and appeals.
• Review information from members, providers, and others; collect and analyze documentation; and make determinations.
• Provide excellent service while demonstrating strong customer service and leadership behaviors.

Skills

Grievance and appeal investigation

CMS regulatory compliance

Medical record and benefit document

Claims adjudication and healthcare

Medical terminology and coding

Documentation review and analysis

Customer service and communication

Critical thinking and decision-making

Microsoft Office and keyboarding

Education

Associate degree in healthcare-related field

Nursing diploma

Job description

Wollborg Michelson Recruiting seeks a Grievance and Appeals Clinical and Administrative Specialist to serve as SME for Part C and Part D grievances and appeals, investigating member, provider, claim processing and customer service issues, coordinating timely resolutions in line with CMS requirements.

Answerable for CMS audits, regulatory compliance, and accurate benefit determinations, this role demands strong analytical skills and attention to detail to deliver quality service in a health plan