Medicare Grievance & Appeals Nurse – Remote

Apolis; Phoenix (AZ); On-site; USD 45,000 - 65,000; Full time

Benefits offered by this job

Remote work option

Job summary

Apolis is seeking a Grievance and Appeals RN in Phoenix, AZ (or remote within AZ time zone) to review and investigate member and provider grievances and appeals for Medicare Part C and Part D. The nurse reviews medical records, claims, authorizations, and plan benefits to make determinations in accordance with CMS requirements and timelines.

The role requires an active Arizona nursing license (RN or LPN), a healthcare degree, and at least 5 years in grievances/appeals, prior authorization,

Qualifications

• RN or LPN with an active, unrestricted Arizona license.
• Associate’s degree in Nursing/Healthcare or Nursing Diploma.
• 5+ years of experience in grievances/appeals, prior authorization, claims, or member services.
• Knowledge of CMS Part C/Part D regulations.
• Experience reviewing medical records and health-plan benefits.
• Knowledge of ICD, CPT, HCPCS, and DRG codes.
• Strong communication, analytical, documentation, and customer service skills.
• Managed care/Medicare experience preferred.

Responsibilities

• Review and investigate complex grievances and appeals.
• Evaluate medical records, claims, authorizations, and benefit documents.
• Apply CMS rules and health-plan policies to case determinations.
• Document investigations and resolutions accurately.
• Work with members, providers, and internal teams to resolve issues.
• Ensure cases are processed within required regulatory timelines.

Skills

Case Management

CMS Part C & Part D knowledge

Managed Care / Health Plan experience

Medical records review knowledge

Strong communication

Education

Associate’s degree in Nursing/Healthcare or Nursing Diploma

Arizona nursing license (RN or LPN)

Job description

Apolis is seeking a Grievance and Appeals RN in Phoenix, AZ (or remote within AZ time zone) to review and investigate member and provider grievances and appeals for Medicare Part C and Part D. The nurse reviews medical records, claims, authorizations, and plan benefits to make determinations in accordance with CMS requirements and timelines.

The role requires an active Arizona nursing license (RN or LPN), a healthcare degree, and at least 5 years in grievances/appeals, prior authorization,